Last Updated Aug 8, 2022
This guide is intended to help donors gain a deeper understanding of the issues related to the U.S. healthcare system and outlines opportunities to address the root causes of inequitable outcomes. See the entire series. By Lucy Brennan-Levine
Good health is a fundamental human right, and health equity efforts aim to ensure that this right is granted to every individual, despite systemic barriers to access. The resources necessary for good health include:
Health equity is often measured by life expectancy, disease rates, and other factors. Research indicates that the U.S. has “higher mortality and inferior health” compared to other developed countries because of a fragmented healthcare system, high uninsured rate, and adverse social and economic determinants, among other issues. The U.S. is one of the only countries that spends more on healthcare but sees lower rates of life expectancy. For example, the U.S. has a life expectancy of 78.69 years, but spends more than $8,700 per capita on healthcare annually, while the United Kingdom spends approximately $3,700 and enjoys a life expectancy of almost 81 years old.
The U.S. continues to struggle with health disparities across class, race, and gender lines. Health disparities are differences in health that are closely related to economic, social, or environmental factors, while health equity is a commitment to address and end those disparities. With this distinction in mind, donors can support pathways to narrow health gaps while increasing access to high-quality healthcare in order to achieve health equity.
For those who are uninsured, high costs can plunge them deeper into cycles of poverty and poor health. Even for those who are insured, coverage may not be enough to lift them out of financial or medical hardship.
A 2019 study found that “29% of Americans failed to take their medications as prescribed because of the cost.” Meanwhile, dental care is crucial to health and wellbeing but not always accessible to low-income individuals. Consider that 40% of low-income and non-Hispanic Black adults have untreated tooth decay.
Approach your giving strategy with the social determinants of health (SDOH) in mind. SDOHs are grouped into five categories, and examples of social determinants include racism, safe housing, and literacy skills.
People of color are likely to make up the majority of the U.S. population by 2050, but discrimination and bias deeply impact health outcomes and affect life trajectories. For example, racism contributes to residential segregation, and studies find that many Black and Hispanic neighborhoods are more likely to lack hospitals and offer low-quality care centers or limited primary care facilities that can help patients with preventative care.
A high level of distrust of the U.S. health care systems is another barrier facing many communities and can lead to poorer health outcomes. For Black Americans and other people of color, medical distrust stems from discrimination in healthcare and the legacy of mistreatment of Black patients within medical systems.
“Weathering” is the concept that chronic exposure to social and economic hardships can lead to deteriorating health patterns. Research shows that Black women experience this at higher rates compared to their white female counterparts. However, weathering is an experience for all communities of color as racism and bias exist in healthcare.
There is evidence to suggest that Black women’s stress and experiences of discrimination are factors in infant and maternal mortality.
Data also suggests that there are higher pregnancy-related mortality ratios among Black and American Indian/Alaska Native women compared to other ethnicities from 2007-2016.
Research shows that normalizing masculine behavior (such as hiding/withholding emotions) in American society can lead to an increase in medical distrust which is linked to fewer preventative screenings. Repressing anxiety, depression, and loneliness in order to appear more masculine also impacts men of color. Only 26.4% of Hispanic and non-Hispanic Black men who had daily feelings of anxiety or depression sought any treatment.
Asian Americans and sub-groups report poor quality of healthcare, communication difficulties with doctors, and less access to preventative services. Poor language training and lack of cultural sensitivity training in the healthcare field contribute to health inequity in Asian American communities. One study captures Asian-Americans’ healthcare experiences:
Asian Americans were less likely than whites to report that their doctors ever talked to them about lifestyle or mental health issues. They were more likely to report that their regular doctors did not understand their background and values. When asked about the last visit, they were more likely to report that their doctors did not listen, spend as much time, or involve them in decisions about care as much as they wanted.
Specific subcultures face varied and serious health challenges: U.S. Filipino individuals are more likely to be obese or overweight, causing high blood pressure and diabetes compared to non-Hispanic white individuals. Additionally, U.S.-born Vietnamese women are four times as likely to die of breast cancer than other Asian American women.
Immigrant communities experience lower rates of health insurance and receive lower quality care. Unauthorized immigrant populations also fear deportation, lowering their likelihood of seeking care, and are not eligible for U.S. health benefits. In California, an estimated 51% of unauthorized immigrants are uninsured. Other factors such as socioeconomic background, English proficiency, residential location, and stigma all contribute to health disparities within immigrant populations.
Poverty is a determining factor in health outcomes and access to healthcare. Low-income families are more likely to reside in communities classified as food deserts, which often lack grocery stores to purchase nutritious foods. Convenience stores and fast food restaurants tend to be more prevalent. In addition, there are fewer mental health supports and facilities in low-income areas.
Individuals experiencing poverty or are considered low income are less likely to be able to afford high-quality healthcare and use fewer preventive care resources.
Those who earn 200% or less of the federal poverty level … and have fewer than three chronic conditions and no functional limitations — have higher health risks, greater social needs, and worse access to care than relatively healthy moderate-income and higher-income people.
Low-income people who use emergency room care cite convenience, cost, and quality of care as reasons for not seeking out primary care pathways to health. “In 2010, African-American patients used the emergency department 54% of the time. In urban areas, the rate was higher, at 59%.”
Finally, children from low-income families are more likely to experience frightening conditions and are exposed to major traumatic events, such as economic hardship or divorce. Adverse Childhood Experiences (ACEs) can have a profound impact on children’s brain development, and result in behavioral and learning problems as well as long-term health issues.
Studies have found both implicit and explicit bias among heterosexual providers against LGBTQ patients. Because of societal stigma, discrimination, and denial of civil and human rights, transgender populations are often at higher risk for homelessness, suicide, and HIV. Discrimination in healthcare and employment perpetuate a higher uninsured rate and despite protections, transgender people are still denied coverage for gender-affirming care in some cases.
“Eighteen percent of LGBT adults have no health insurance, while 13% of non-LGBT adults lack health insurance. When LGBT people do access health care, they often encounter providers that lack the expertise to provide effective care.
More than one billion people worldwide are estimated to experience or live with a disability and face challenges trying to obtain high-quality healthcare. These include attitudinal barriers, physical barriers, communication, and financial barriers.
Many disabilities come with specific challenges.
Furthermore, individuals with disabilities are less likely to receive preventative healthcare, less likely to have an annual dental visit, and are less likely to receive recommended cancer screenings than individuals without disabilities.
Communication and facility-based barriers add more complications. Hospitals don’t prioritize disability competency training for medical professionals and healthcare practitioners. At the policy level, there are issues that contribute to disability exclusion in hospitals: Hospitals don’t face financial repercussions for non-compliance, ADA compliance isn’t a focus for hospital accreditation, and there aren’t strict regulations against hospitals buying inaccessible medical equipment.
Public health policy or lack thereof can restrict access for individuals that need stable and consistent high-quality healthcare. People of color are more likely to be uninsured – several states with large Black populations have refused to expand Medicaid coverage.
If the remaining states implemented expansion, at least 4 million additional uninsured adults would become eligible for Medicaid coverage, likely more due to the recession. Of these, nearly 60 percent are people of color.
There is evidence that expanding Medicaid coverage can lead to improvements in access, financial security, and some measures of health status/outcomes.
Historically, strong public health policy can contribute to significant life changes and positive health outcomes, such as vaccinations for school children, safer workplaces, and improvements in reproductive services and family planning.
At the state level, policies can have a large impact on local populations, especially ones that are marginalized. In New York and Texas, health regulations mandated that private insurance must cover 3-D mammograms with no out-of-pocket costs, helping increase access to breast cancer preventative care, which is significant for Black women, who are 43% more likely to die than white women. In Washington State, a 2021 bill prohibits health insurers from discriminating against policyholders based on gender expression and identity, which specifically strengthened protections for transgender patients seeking gender-affirming treatment.
State and federal health policy that makes healthcare affordable and accessible could help to improve disparities that many Americans face regarding their healthcare access and services.
Your zip code can be a determining factor in your health outcomes. Emerging research indicates that life expectancy can range 20 years apart between neighborhoods. Individuals living in rural areas run into several barriers to accessing healthcare services, including lack of primary care hospitals in the area, healthcare workforce shortages, limited health insurance coverage, limited broadband access for telehealth, and poor health literacy.
Rural Americans tend to have higher rates of cigarette smoking, high blood pressure, and obesity. Rural residents report less leisure-time physical activity and lower seat belt use than their urban counterparts. They also have higher rates of poverty, less access to healthcare, and are less likely to have health insurance. All of these factors can lead to poor health outcomes.
Strategies such as reducing costs, promoting health education, employment opportunities, and policies expanding public health coverage can help tackle health equity issues in rural areas (and throughout the country).
National statistics do not include data on health disparities for smaller populations, such as American Indians and Alaska Natives or Native Hawaiian and other Pacific Islanders. Disaggregated data could help policymakers understand health disparities and tailor policies accordingly. Since there are several gaps within existing data sources to measure health disparities and inequities, some populations will be left out of policy aimed at creating equitable health outcomes. Additionally, the federal government data has minimal criteria or expectations for demographic data, making it difficult to access research that accurately reflects population health struggles and community needs.
Pushing to improve how we collect data, and improving processes for measuring and understanding different population needs across the social determinants of health can ultimately help create pathways for health equity.
Funders looking to drive meaningful change in addressing health disparities should consider focusing on improving infrastructure across the broader healthcare sector and addressing the root causes of disparities. Additionally, building power in communities can serve as an approach to address health inequity.
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