Ending Unequal Treatment Strategies to Achieve Equitable Health Care and Optimal Health for All (2024) / Chapter Skim
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2 The Health Care System Within a Larger Societal System
2 The Health Care System Within a Larger Societal System
Pages 49-78
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From page 49... ...
. Moreover, as emphasized by the Healthy People 2030 framework, merely addressing factors contributing to inequitable health care access and quality alone cannot improve the factors contributing to poor health and health care outcomes across and between social groups.
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Ameliorating the factors preventing individuals and social groups from achieving their best health possible or attaining their full health potential requires also addressing the societal, environmental, economic, and political forces that develop and exist well before individuals enter the health care system. Research has shown how these social, political, economic, and environmental conditions that adversely impact racially and ethnically minoritized groups consistently lead to health and health care inequities (Lucyk and McLaren, 2017; Plamondon et al., 2020; Taylor et al., 2016)
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Finally, a societal commitment to equity is an external force that is essential to eliminating health inequities and needs to be cultivated and nurtured. STRUCTURAL DETERMINANTS OF HEALTH Structural determinants of health are defined as "cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)
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Market-driven systems lead to significant differences in outcomes according to the ability to pay (as an example of how social norms have influenced the health care sector, see Box 2-1 for a discussion on health care financing and insurance design)
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Instead, the systematically higher representation of minoritized populations in lower-reimbursement health care, particularly in Medicaid, is a historical incentive to provide unequal treatment. Even though out-of-pocket costs are lower in Medicaid than in private insurance, the amount that provid ers receive is much lower, often for providing care in more challenging circumstances and to less-resourced patients.
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. Structural Racism2 and Health Outcomes Although multiple societal factors affect health and health care inequities, it is the health and health care differences by race and ethnicity that remain the most persistent and difficult to address (NASEM, 2017; Williams and Mohammed, 2009)
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. Many studies characterize its role in driving inequitable health and health care outcomes among minoritized populations (Bailey et al., 2017; Hailu et al., 2022; Muramatsu and Chin, 2022; O'Brien et al., 2020; Wang et al., 2023; Wien et al., 2023; Yearby et al., 2022)
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Structural racism is most commonly implicated in creating health and health care disparities, but interpersonal racism also plays a role, with research highlighting this connection between perceived interpersonal racism and the risk of stroke in Black women (Sheehy et al., 2023)
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. Internalized Racism and Health Outcomes Despite significant evidence to support interpersonal racism's impact on poor health outcomes and a growing body of evidence that structural racism adversely impacts health outcomes, less scientific attention has been paid to internalized racism (David et al., 2019)
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The unequal distribution of health-promoting and -damaging resources in those environments, along with a myriad of historical and current societal forces, contributes to unequal health and health care outcomes across racial and ethnic populations (NASEM, 2017)
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. Investigators have also documented variation in intergenerational economic mobility, with significant advancement among Hispanic but not Black people (Chetty et al., 2020)
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. Health Care Access and Quality While the health care system is discussed in greater detail throughout this report, access to quality health care is included in SDOH by many experts because it is shaped by economic and societal forces.
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. Unhealthy food environments, in the form of food deserts and food swamps, are associated with the community context that drives inequitable health outcomes in populations.
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. This increasingly robust evidence base has led to a growing recognition throughout the health care delivery system that improvement in health and health care outcomes depend at least in part on addressing the social,
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For example, they provide food or to address food insecurity, offer housing resources to address housing insecurity, or cover transportation costs (Castrucci and Auerbach, 2019)
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as well as continuing education programs should incorporate competency-based curricula on social care. Curricula should include evidence on the social determinants of health, protocols for working in interprofessional teams to address social needs in health care settings, interpersonal and organizational approaches to advancing health equity and decreasing health dispari ties, and competencies relating to collecting, securing, and using data and technology to facilitate social and health care integration.
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Funders of health care workforce research (e.g., the Agency for Healthcare Research and Quality and foundations) should include the social care workforce in studies of the effect of the social care workforce on the health and financial outcomes of health care delivery organizations.
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For example, health care providers, insurance companies, employers, and government agencies have competing self- interests in an already fragmented health care system, avoiding a collective responsibility for comprehensively advancing health equity. Second, the health care system lacks effective cooperation and collaboration among players in achieving overall population health goals.
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SOCIETAL COMMITMENT TO EQUITY Little progress can be made to advance equity without a will and commitment to change the status quo. Although many forces threaten the advancement of equity, much support exists for achieving equitable health and health care outcomes for all.
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. Health equity should become a core competency for all health professionals; curriculum components would include a focus on population health, structural and social determinants of health, and health inequities (Gonzalo et al., 2020)
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Conclusion 2.6. Lack of societal commitment to racial and ethnic health equity at multiple levels across the life course has hindered progress to advance health care equity.
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2021. The impacts of collaboration be tween local health care and non-health care organizations and factors shaping how they work: A systematic review of reviews.
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2021. Social and structural determinants of health inequities in maternal health.
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2017. Implicit bias in healthcare professionals: A systematic review.
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2021. Adverse childhood experiences and justice system contact: A systematic review.
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2018. Using the index of concentration at the extremes at multiple geographical levels to monitor health inequities in an era of growing spatial social polarization: Massachusetts, USA (2010–14)
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2020. The integration of evi dence from the commission on social determinants of health in the field of health equity: A scoping review.
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2017. Systematic literature review of built environment effects on physical activity and active transport - an update and new findings on health equity.
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2015. Achieving health equity by design.
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