Richard M. Scheffler & Olivia Shane (Milbank Quarterly 12/6/2021)

Health equity has become a familiar buzzword in public health. There is, however, little consensus about what it means and how to measure it. California, the most diverse of all states, recently used principles of health equity in its response to the COVID-19 pandemic. The state is currently working on two important new developments in health equity: legislation to establish a health equity fund, and Medi-Cal waivers to address health equity.

Defining Health Equity

Braveman and colleagues defined health equity as meaning that “everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, powerlessness, and their consequences—including lack of access to good jobs with fair pay, safe environments, and quality education, housing, and health care.” This definition explicitly places the concepts of fairness and justice at the heart of the notion of health equity. The idea of health equity is also based on theories of social and distributive justice. This means that health care is distributed according to need and not based on personal characteristics or economic and social position. We find this definition the most useful and compelling. One way to visualize what health equity means in more concrete terms is to imagine a pair of dice being tossed to determine who will have better and who will have worse health. The dice historically have been loaded in favor of white, wealthy, and powerful individuals, and against people of color, low-income individuals, and those who lack political representation. A fair and just opportunity for health might mean unloading the dice, so that everyone has an equal chance at being as healthy as possible. Efforts to achieve health equity should not, however, allocate equal resources or treatment for everyone. Equalizing chances to be healthy requires allocating greater resources and support to those who have previously been excluded or marginalized. Those who have experienced social disadvantage need more, not merely equal, attention to address the health damage caused by discrimination, economic hardship, and powerlessness.Health disparity is a closely related but distinct concept. Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with economic, social, or environmental disadvantage.” Braveman writes that the core concept of health disparities is based on “…concerns about social justice—that is, justice with respect to the treatment of more advantaged vs. less advantaged socioeconomic groups when it comes to health and health care.” If we eliminated all disparities, we would have an equitable health care system.

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