Chapter Twelve Equality and Inequality in American Health Care 1 2 2 Health Inequalities and Inequities Some people have longer and healthier lives. These differences are closely associated with social characteristics such as race, ethnicity, gender, location, and socioeconomic status. Knowledge and understanding of health inequalities has increased. 3 What are Health Inequities? What is the definition of health? Narrow definitions focus on the absence of disease. More expansive definitions of health may include happiness, freedom from disability, quality of life, and the capacity to lead a socially meaningful and economically productive life. 4 Assessing Health Status There are many ways to assess health status. The most common health indicators are mortality, survival, life expectancy, disease incidence, and disease prevalence. Composite measures such as DALY and QALY can be used to compare difference health conditions. 5 Assessing Health Status There are many ways to assess health status. More expansive measures may include physiological indicators of overall health, health status, a sense of well-being, and social connectedness and productivity. 6 Measures of Health Care Discussions of health inequalities may also utilize measures of health care, including rates of diagnosis, treatment, cost, insurance coverage, quality, survival, symptom reduction, or some other health outcome measure. Health inequalities should be distinguished from inequalities in health care. 7 Inequality A health inequality is a descriptive term referring to either to the total variation in health status across individuals within a population, or a difference in average or total health between two or more populations. It involves comparing population averages. 8 Health Inequities Health inequity is a normative term that refers to a difference that is judged to be morally unacceptable. While all health inequities are by definition health inequalities, not all health inequalities are health inequities. 9 Health Inequities Determining whether a particular inequality (or class of inequalities) constitutes an inequity requires a moral judgment based on a priori beliefs about justice, fairness, and the distribution of social resources. Relative social position of different populations assists defining inequity. 10 Health Inequities Rawls’ difference principle is used when addressing health inequities. Social justice can indicate that a given population has disproportionately suffered from international military and economic exploitation, inequitable distribution of economic resources, or historical patterns of race-based economic and social injustice. 11 Health Inequities Drawbacks of using a population approach include: The a priori identification of disadvantaged populations may be contentious or arbitrary. Neglect of situations in which a genuinely unjust distribution of health may benefit those in socially superior positions. 12 ...

1. Chapter Twelve
Equality and Inequality in American Health Care
1
2
2
Health Inequalities and Inequities
Some people have longer and healthier lives.
These differences are closely associated with social
characteristics such as race, ethnicity, gender, location, and
socioeconomic status.
Knowledge and understanding of health inequalities has
increased.
3
What are Health Inequities?
What is the definition of health?
Narrow definitions focus on the absence of disease.
More expansive definitions of health may include happiness,
freedom from disability, quality of life, and the capacity to lead
a socially meaningful and economically productive life.
4

2. Assessing Health Status
There are many ways to assess health status.
The most common health indicators are mortality, survival, life
expectancy, disease incidence, and disease prevalence.
Composite measures such as DALY and QALY can be used to
compare difference health conditions.
5
Assessing Health Status
There are many ways to assess health status.
More expansive measures may include physiological indicators
of overall health, health status, a sense of well-being, and social
connectedness and productivity.
6
Measures of Health Care
Discussions of health inequalities may also utilize measures of
health care, including rates of diagnosis, treatment, cost,
insurance coverage, quality, survival, symptom reduction, or
some other health outcome measure.
Health inequalities should be distinguished from inequalities in
health care.
7
Inequality
A health inequality is a descriptive term referring to either to
the total variation in health status across individuals within a
population, or a difference in average or total health between
two or more populations.
It involves comparing population averages.
8

3. Health Inequities
Health inequity is a normative term that refers to a difference
that is judged to be morally unacceptable.
While all health inequities are by definition health inequalities,
not all health inequalities are health inequities.
9
Health Inequities
Determining whether a particular inequality (or class of
inequalities) constitutes an inequity requires a moral judgment
based on a priori beliefs about justice, fairness, and the
distribution of social resources.
Relative social position of different populations assists defining
inequity.
10
Health Inequities
Rawls’ difference principle is used when addressing health
inequities.
Social justice can indicate that a given population has
disproportionately suffered from international military and
economic exploitation, inequitable distribution of economic
resources, or historical patterns of race-based economic and
social injustice.
11
Health Inequities
Drawbacks of using a population approach include:
The a priori identification of disadvantaged populations may be
contentious or arbitrary.
Neglect of situations in which a genuinely unjust distribution of

4. health may benefit those in socially superior positions.
12
Health Inequities
A common definition of health inequity focuses on the causes
and consequences of a given health inequality.
A systematic health inequality is one that consistently affects
two or more populations and is not the result of random
variation.
13
Health Inequities
Avoidability has several components.
Health inequities must be technically avoidable ; a successful
means of reducing the inequality must exist.
They must be financially avoidable; sufficient resources exist to
rectify the inequality.
They must be morally avoidable rectifying the inequality must
not violate some other social value, such as liberty or
distributive justice.
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Health Inequities
Unjust cause is also a criterion. It can include:
Health-damaging behavior where the degree of choice of
lifestyles is severely restricted.
Exposure to unhealthy, stressful living and working conditions.
Inadequate access to essential health and other public services.
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Health Inequities
Problems with the cause definition include:

5. Patterns are not morally wrong.
We choose to categorize patterns as unjust.
Justice when high-risk health behaviors are “freely chosen” is a
topic of considerable debate.
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Health Inequities
The most significant problem with this definition is that many
health problems have multi-causal etiologies.
Another issue is that an inequality might be designated as
morally wrong because it is part of a morally wrong situation.
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Measurement
Determining whether a specific situation is inequitable requires
that the health status of at least two populations be measured
and compared.
One must determine which populations to compare and
The most appropriate measures that should be used in
comparing these populations.
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Measurement
For analysis, populations should differ in ways that are socially
or morally important.
On should establish a comparison group that serves explicitly
as a reference against which one or more populations are
compared.
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6. Measurement
Criteria for a comparisons group could be:
Total population average.
The best-off population.
The most socially advantaged population.
Some independently-defined target rate.
20
Measurement
A wide variety of statistical measures of inequality are
available, from simple averages to sophisticated measures of
total inequality.
The absolute difference is a number resulting from subtraction
of the numerical measure of one group’s health status from
another.
21
Measurement
The relative difference is a ratio resulting from divi sion of the
numerical measure of one group’s health status from another.
The choice of appropriate measures is important when
considering the ability to address inequalities and overall
health.
22
Reducing or Eliminating Health Inequalities
One must consider the relationship between equality of
treatment and equality of outcomes.
Horizontal equity refers to the equal allocation of resources
across a population.
Vertical equity refers to the allocation of different resources for
different levels of need.

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Reducing or Eliminating Health Inequalities
The issue of health inequity has not been completely addressed
despite healthcare reform and other efforts to eliminate it.
Efforts to address these issues should be based on accurate
information and analysis.
Despite the challenges, there is a moral duty to continue to
address issues related to health inequalities and inequities.
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In Summary…
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