Part II: Health Equity in the U.S. and How Hp 2020 Incorporates Health Equity
A. Health Equity, Health Disparities, and Federal Efforts to Eliminate Health Disparities
Much has been written about the difficulty of defining health equity and in developing a framework for determining which health disparities should be considered unjust and thus subject to redress. To establish why health should be distributed equitably necessarily implicates the human right to health, which was first iterated in the 1948 Universal Declaration of Human Rights and restated in the World Health Organization (WHO) Constitution as “[t]he enjoyment of the highest attainable standard of health . . . without distinction of race, religion, political belief, economic or social condition.” Although it is intuitive that health is important and that rational people want a high level of health, it is useful to consider various theoretical bases for the importance of health as a human right--once the critical nature of health to the human experience is established, the social justice and philosophical reasons for equitable distribution of health become clearer.
1. The Importance of Health Equity
Among all other rights, the case is often made that health is special in that it has a particular significance to individuals--without health, individuals cannot fully function as human beings. Martha Nussbaum developed the “capability to function” framework, in which just societies should aim to give their citizens certain basic functional capabilities, including “[b]eing able to live to the end of a complete human life, as far as is possible; not dying prematurely; . . . [b]eing able to have good health; to be adequately nourished; [and] to have adequate shelter.” Nobel Laureate economist Amartya Sen considered the capability to avoid preventable ill-health and premature mortality to be an instrumental human freedom, arguing that expansion of fundamental freedoms, including health, is both the primary end and principal means of development. Without this capability for health and other fundamental freedoms, Sen argued, people are not free to do things that a person “has reason to value.” Incorporating Sen's theory, the WHO Commission on the Social Determinants of Health spoke of concern for people who, by virtue of ill-health, are “without the freedom to lead flourishing lives.” The Commission observed that, in addition to its intrinsic value, health also serves an instrumental function, allowing people to fully participate in society, with potentially positive consequences for economic development. In essence, health is requisite for much of what is considered a full life--the ability for individuals to “recreate, socialize, work, and engage in family and social activities that bring meaning and happiness to their lives.” Moreover, in explaining why health is essential not only for individual functioning, but also for population health, Gostin observes:
Without minimum levels of health, people cannot fully engage in social interactions, participate in the political process, exercise rights of citizenship, generate wealth, create art, and provide for the common security . . . . Population health becomes a transcendent value because a certain level of human functioning is a prerequisite for activities that are critical to the public's welfare--social, political, and economic.
Thus, it is not possible to have a well-functioning society if health disparities exist such that disadvantaged population segments are unable to fully participate in the essential activities of society.
2. Defining “Health Equity” and “Health Disparities”
Having established the importance of health to individual and population functioning, the question arises as to what exactly is intended by the terms “health equity” and “health disparities.” Why should society care about the distribution of health across populations, irrespective of averages, and what obligation should governments have to seek an “equitable” distribution of health? If it is incumbent on government to take steps to enable individuals and populations to achieve health, a degree of relative precision about that obligation is necessary to allow meaningful assessment of progress. Although public health practitioners and scholars often take as self-evident that health disparities based on social disadvantage are unjust, the concept of health equity is far from accepted in mainstream political discourse, particularly when tangible measures to reduce health disparities are concerned. Thus, it bears discussing the philosophical and social justice rationales in support of government obligation to further the achievement of health equity.
As Asada observed, the use of the term “equity” in connection with health is intended to convey a moral judgment--that greater health disparities are less desirable than smaller health disparities. Stated differently, there are moral implications of the distribution of health within and among societies. Various moral justifications have been offered in support of health equity. One is based on the concept discussed above of health as a special good. If one accepts that health is essential to human flourishing, then “is it not inevitable that we pay particular attention to health equity?” Others tie the concept of health equity more closely to general philosophical notions of equality and justice, particularly the notion of ensuring equitable distribution of essential capabilities. However, unlike those who argue that health is a special good, this approach regards health as one of a number of goods whose distribution is morally significant, but not automatically deserving of elevation above other goods. A third approach views the distribution of health among a population as an indicator of general social justice. Under any of these approaches, the question arises as to what exactly constitutes an “equitable” distribution of health.
Incorporating the theories of Nussbaum, Sen, and others, members of a subcommittee of the Secretary's Advisory Committee for HP 2020 (the Subcommittee) attempted to provide a tangible basis for assessing progress by developing proposed definitions for health equity and health disparities that should be applied to HP 2020 and to U.S. public health policy in general. HP 2020 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.” The Subcommittee further explained that health equity is
the value underlying a commitment to reduce and ultimately eliminate health disparities . . . . Health equity means social justice with respect to health . . . . Health equity means striving to equalize opportunities to be healthy. In accord with the other ethical principles of beneficence (doing good) and nonmalfeasance (doing no harm), equity requires concerted effort to achieve more rapid improvements among those who were worse off to start, within an overall strategy to improve everyone's health.
The Subcommittee does not view health equity from a strictly egalitarian view because it expressly rejects the possibility of closing health gaps by worsening advantaged groups' health (the so-called “leveling-down” objection). This explanation is consistent with the general global health understanding of health equity, which the WHO describes as existing when “all people have an equal opportunity to develop and maintain their health, through fair and just access to resources for health.” However, the Subcommittee's explanation of health equity does not specify which health disparities must be eliminated in order for health equity to exist. It is not possible to eliminate all health disparities because certain health factors are not amenable to government intervention, including genetic factors and some behavioral risk factors where government interference with individual decision-making would be at odds with democratic ideals. But a cogent theory for determining what constitutes unjust health disparities is necessary because, as the Subcommittee explained, “[r]eductions in health disparities (by improving the health of the socially disadvantaged) are the metric by which progress toward health equity is measured.”
Asada described three competing theories for determining which health disparities should be considered unjust and thus subject to government intervention. The first incorporates the historic practice of conducting empirical analysis of health equity by considering health disparities correlated with socioeconomic status. This theory, popularized by Hausman, suggests that we are concerned with health disparities based on SES because poor health tends to correlate with less success in other valued spheres of life, such as income, occupation, and education. Another theory, led by Whitehead, incorporates the value of individual choice:
Judgments on which situations are unfair will vary . . . but one widely used criterion is the degree of choice involved. Where people have little or no choice of living or working conditions, the resulting health differences are more likely to be considered unjust than those resulting from health risks that were chosen voluntarily.
This theory attempts to balance the sometimes competing interests of health and autonomy, and the obvious difficulty is determining which factors are truly beyond or within individual control, and to what degree. For example, in assessing levels of physical activity across socioeconomic groups, the “individual choice” theory would undertake to determine the degree to which residents of certain neighborhoods (usually low income) have less access to safe recreational facilities, thereby diminishing the ability of residents to maintain sufficient levels of physical activity, before determining whether the disparity would be considered unjust.
Finally, the third theory, which is largely adopted by the Subcommittee in its definition of health disparities, concerns itself not with the precise causes of disparities or the degree of individual choice, but whether the causes are amenable to human intervention. So, in the physical activity example above, the “amenable to human intervention” theory would determine that differences in physical activity levels based on neighborhood are unjust, irrespective of the recreational facilities available, because the disparity would be susceptible to human intervention in the form of programs designed to increase physical activity. Thus, the choice of theory is important because different governmental obligations are implied by each in certain circumstances. As another example, health disparities based on risky individual behavior such as riding a motorcycle without a helmet would be regarded as inequitable under a strict interpretation of the amenable to human intervention theory, but not under the SES or individual choice theories.
Varying definitions of health disparities have been adopted by governments and international organizations, reflecting incorporation of one or more of the theories described above. In its landmark report, “Closing the Gap in a Generation,” the WHO Commission on the Social Determinants of Health explained “[w]here systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair.” Moreover, the Commission said, “[p]utting right these inequities - the huge and remediable differences in health between and within countries - is a matter of social justice. Reducing health inequities is . . . an ethical imperative.” Writing for the Commission in a complementary article published in The Lancet, Sir Michael Marmot explained, “Not all health inequalities are unjust or inequitable. If good health were simply unattainable, this would be unfortunate but not unjust. Where inequalities in health are avoidable, yet are not avoided, they are inequitable.” Thus, the WHO Commission seems to rely primarily on the amenable to human intervention theory in determining which disparities are unjust and thus require societal action.
HP 2020 defines health disparities as “particular type[s] of health difference[s] that [are] closely linked with social, economic, and/or environmental disadvantage.” In addition, HP 2020 explains that “[h] ealth 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.” The Subcommittee, however, defines health disparities in a slightly different way: “Health disparities are systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups.” Importantly, the health differences must be both systematic--i.e., not isolated or exceptional findings--and they must be systematically linked with social disadvantage (but causation need not be definitively established).
The Subcommittee considers that health differences associated with social disadvantage raise special social justice concerns because ill-health reinforces and/or compounds the negative effects of social disadvantage, making it more difficult to overcome. The component of the definition requiring that the health differences be “plausibly avoidable” evokes the amenable to human intervention framework discussed above. The Subcommittee explained that “plausibly avoidable” intends to convey that “[i]t must be plausible, but not necessarily proven, that policies could reduce the disparities . . . [T]he criterion is whether the given condition is theoretically avoidable, based on current knowledge of plausible causal pathways and biological mechanisms, and assuming the existence of sufficient political will.” Acknowledging political reality and limited resources, the Subcommittee does not establish an obligation that all theoretically avoidable health differences are disparities (as the amenable to human intervention framework implies); rather the Subcommittee seems to establish a sort of sliding scale, stating that “[t]he more solid the knowledge, the more reasonable and politically viable it will be to invest resources in interventions; feasibility, costs, and potentially harmful unintended consequences must be considered.”
The Subcommittee's definition of health disparities raises a critical question for measurement and assessment purposes--What factors constitute “social disadvantage” such that correlated health differences should be considered (unjust) health disparities? The Subcommittee says that “social disadvantage” refers to the “unfavorable social, economic, or political conditions that some groups of people systematically experience based on their relative position in social hierarchies.” In addition, social disadvantage means “restricted ability to participate fully in society and enjoy the benefits of progress . . . [and] is reflected, for example, by low levels of wealth, income, education, or occupational rank, or by less representation at high levels of political office.” This definition is quite broad and could prove infeasible for purposes of assessing progress. Perhaps for this reason, for measurement purposes, HP 2020 takes a slightly narrower view. HP 202 0 says that, for purposes of assessing U.S. progress toward eliminating disparities over the coming decade, it will measure results across the following factors: income, race and ethnicity, gender, sexual identity and orientation, disability status or special health care needs, and geographic location (rural and urban).
3. The Federal Government Role in Health Equity
HP 2020 is not the first instance in which the federal government has made disparities a national health priority. Federal recognition of health disparities related to SES and race or ethnicity dates to at least 1985, with the release of the congressionally mandated “Report of the Secretary's Task Force on Black and Minority Health,” which documented a significant pattern of disparities among racial and ethnic groups. Shortly thereafter, the Office of Minority Health was established within HHS and today exists within six federal agencies. In 1998, President Clinton announced the Initiative to Eliminate Racial and Ethnic Disparities in Healthcare, the goal of which was to eliminate racial and ethnic health disparities in six key areas of health status by 2010. When the HP 2010 goals were released, one of the two overarching goals was the elimination of health disparities.
The federal focus on disparities has increased in the last decade, particularly since 2002, with the release of the Institute of Medicine's (IOM) landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, which documented significant disparities in health care. Since then, the Agency for Healthcare Research and Quality (AHRQ) has issued yearly National Health Disparities Reports, which document healthcare-related disparities among racial, ethnic, and socio-economic groups in the United States. In 2011, the CDC issued its first “Health Disparities and Inequalities Report,” containing a broad array of health disparities measurements, including those based on SES, race or ethnicity, geography, and others. Most recently, thousands of community and government leaders collaborated on the National Partnership for Action to End Health Disparities (NPA), sponsored under the auspices of HHS. The NPA was created to “mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity.” The result of this collaborative effort is the “National Stakeholder Strategy for Achieving Health Equity,” which is described as “a roadmap for eliminating health disparities through cooperative and strategic actions.” In addition, the collaboration resulted in the “HHS Action Plan to Reduce Racial and Ethnic Health Disparities,” which outlines specific HHS actions in regard to racial and ethnic health disparities, building on provisions of the Affordable Care Act. Unfortunately, notwithstanding the various federal initiatives to address health disparities, progress has been slow, and, since 2000, virtually nonexistent. In light of the lack of progress even in the face of what appears to be a significant federal effort, it is fair to ask whether federal policies have truly prioritized reduction of disparities.
In addition, when considering health equity and disparities it is helpful to place the United States in context relative to other developed countries, in regard to both statistics and the legal environment. Although precise country comparisons are difficult given the differences in the way countries monitor health and health disparities, in general, the state of health equity in the U.S. appears to be worse than in most industrialized nations. For example, among lower SES groups in the U.S. and Canada (which has generally adopted more interventionist health promotion approaches than the U.S., including a national health care system), adverse personal health-related behaviors have a more significant impact on the U.S. cohort than on the comparable Canadian group. Similarly, differences in health outcomes by racial and ethnic group are more pronounced in the U.S. than in Canada.
Finally, from a policy perspective, it is useful to observe the close interaction between efforts to reduce disparities and efforts to address what are referred to as the “social determinants of health.” HP 2020 (and other U.S. health policy initiatives) consider social determinants of health to be the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Differences in health status that are linked to these factors reflect a lack of health equity. An advantage of the amenable to human intervention theory in addressing social determinants is that it avoids to some extent the implicit “blame” contained in the individual choice theory, recognizing that even health inequalities based on modifiable personal behavior are influenced by external factors. Thus, the amenable to human intervention theory implicitly views disparities in the context of the social determinants of health. In this framework, strategies to achieve health equity must necessarily incorporate approaches to mitigate the effects of the social determinants of health--that is, strategies to reduce health disparities must be directed at factors beyond traditional health care services. The strong influence of the social determinants of health on ultimate health outcomes presents a particular challenge for HP 2020 in that many of the factors are outside the traditional purview of HHS--indeed, this jurisdictional issue may account for the fact that the social determinants of health are the only topic for which HHS has not yet set objectives and indicators.
B. The Healthy People 2020 Goals In Relation To Health Equity
The Healthy People Initiative describes its work as providing “science-based, 10-year national objectives for improving the health of all Americans,” and, since its inception roughly thirty years ago, Healthy People has “established benchmarks and monitored progress over time in order to: encourage collaborations across sectors[,] empower individuals toward making informed health decisions, [and] [m]easure the impact of prevention activities.” HP 2020 is the latest in a series of Healthy People goals, which have been issued roughly every ten years since 1979, with each iteration becoming more ambitious in seeking to address the pressing health problems of the U.S. through the addition of new topic areas and objectives. HP 2020 builds on the achievements and shortcomings of prior Healthy People goals, most recently HP 2010.
Key changes from HP 2010 to HP 2020 include a movement from two overarching goals to four (though, in both the 2010 and 2020 iterations, the elimination of disparities is an overarching goal), the inclusion of social determinants of health as an explicit focus, as well as the addition of a number of new topic areas. In evaluating the goals of HP 2020, it is noteworthy that the HP 2010 final review found that the areas of weakest progress were in regard to obesity and health disparities, which essentially did not improve over the decade in which HP 2010 was in effect. This lack of improvement is disappointing, but it is perhaps unsurprising that overall health disparities did not improve during the term of HP 2010. Although there were many federal efforts to monitor disparities, as described above, in the context of overall population health efforts, very little was done to directly address the causes of health disparities.
While the approach of making the elimination of disparities an overarching goal that theoretically applies to all targets and objectives is effective in that the goal is implicitly incorporated in every objective, this approach also creates potential problems when looking at the specific objectives. Just as in HP 2020, HP 2010 very rarely advocated for specific legal mechanisms such as direct regulation or taxation, even where public health evidence supported such interventions. Without direct action, it is unlikely such disparities will remedy themselves. Given that HP 2010 acknowledged that disparities were an area of particularly weak progress, HP 2020 presents an opportunity for relevant governmental agencies to take a new approach in policy formulation--explicitly acknowledging the distributive impacts of policy choices and advocating for specific measures, particularly coercive legal mechanisms, to reduce disparities in addition to improving population health, rather than setting broad population health targets with no specific recommendations for their achievement.
This distributive approach is essential to an effort to achieve health equity. HP 2020 incorporates health equity as a pillar upon which the HP 2020 goals are conceived. In addition to the many specific goals discussed herein, HP 2020 has four overarching goals:
• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death;
• Achieve health equity, eliminate disparities, and improve the health of all groups;
• Create social and physical environments that promote good health for all;
• Promote quality of life, healthy development, and healthy behaviors across all life stages. In addition, HP 2020 utilizes four foundational health measures to measure progress towards achieving these goals:
• General Health Status
• Health-Related Quality of Life and Well-Being
• Determinants of Health
• Disparities
As discussed above, health disparities are almost always considered to reflect a lack of health equity; thus, utilizing disparities as a foundational health measure of progress ensures that health equity will remain a key focus area as progress toward the HP 2020 goals is measured. While improvement in each of the other three foundational health measures is obviously both desirable and necessary to achieving the HP 2020 goals, improvement in those three measures alone will not inevitably signal progress toward health equity because health equity necessarily involves elimination of disparities. In Part III, this paper discusses the particular importance assessing the distributive consequences of policy interventions and why coercive legal mechanisms are essential to achieving the population health objectives of HP 2020 while also reducing disparities.
