Equity and Practicality in Health Disparities Research John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University School of Medicine

Learning Objectives Explain meanings of “health equity” and “healthcare equity.” Understand links to equality, justice, and respect. Explain practical implications for health disparities research.

Health Disparities Clarity & Practicality Clear Definitions Clear Indications Healthcare Social policy Braveman et al. (2011) AJPH

Respect Everyone has equal and substantial moral worth and their equal worth is recognized, honored, and ensured.

Health Disparities “Health differences that adversely affect socially disadvantaged groups.” –“plausibly avoidable” –Assoc w/ “discrimination or marginalization” “Disparities in health and its determinants are the metric for assessing health equity.” Braveman et al. (2011) AJPH

Equity & Disparities Health Equity Core value Eliminate Disparities Braveman et al. (2011) AJPH

Soc Justice Rights Health Equity Health Disparities

Equity & Practicality In health disparities research –The concept of health equity is practically important. Yes/No (Example) –The concept of healthcare equity is practically important. Yes/No (Example)

Ethical Actions Ethical Actions Possible Actions Possible Actions

Ethical Actions Ethical Actions Practical = Possible Practical = Possible & = “Plausible” = = Reasonably Possible? or =Should do, all moral factors considered Practical = Possible & = “Plausible” = = Reasonably Possible? or =Should do, all moral factors considered

Equity & Practicality Is the concept “health equity” practically helpful in health disparities research? –Gives helpful ethical guidance and/or –Provides helpful new guidance and/or –Facilitates what should be done

Health Disparities Research Is the concept of health equity of practical significance? Is it practically helpful? If so, how or why?

Justice Equity Equality

Equity, Rights, Health, Healthcare Ethical Right to health/healthcare: 1 o or 2 o (R1/R2) Equitable H/Hcare –Fair honoring of R1/R2 –Not overridden by other Rs & additional ethical factors as determined through a fair deliberative process

Equity (& Equality) Feature of justice Justice as Fairness –Likes are treated alike (equality) –To each (grp, individ) what is due (e.g. equal opportunity) –Priority to the worse off, especially worst off –Outcomes of a decision procedure that employs appropriate ethical guidelines, including fair equality of opportunity for participation.

Equity in Health/Healthcare Fair opportunity for a sufficient level of health* –Just distribution of social determinants –Genuine access to needed healthcare –Needed healthcare Remediation of deficiencies, given no overriding ethical considerations *Powers, M., & Faden, R. (2006)

Practicality & Disparities Research Healthcare Equity –Fair & substantial equal opportunity for access Sort by challenges: poverty, language, education, etc. Structural barriers: agencies, policies System facilitators –Equality after system entry Quality improvement outcomes System “treatment” (policies, procedures, personnel)

Causality & Practicality “It must be plausible, but not necessarily proven, that policies could reduce the disparities, including not only policies affecting medical care but also social policies addressing important nonmedical determinants of health and health disparities, Braveman et al. (2011) AJPH

Health Equity, Social Disadvantage Health Sciences Centers Does health equity, a form of social justice, require that health sciences centers work to eliminate unfair inequalities in social determinants that contribute to health disparities? Why/why not? If so, how?

Equity: Health & Healthcare Does health equity require that healthcare institutions/systems assess outcomes by race/ethnicity, gender, sexual orientation, language, socioecon status, geographic location, etc.? Why/why not? If so, how?

References Braveman, P. A., Kumanyika, S., Fielding, J., Laveist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101 Suppl 1, S Powers, M., & Faden, R. (2006). Social justice: The moral foundations of public health and health policy. New York: Oxford Univ. Press.