What is equity? Equity is the experience of justice: of treatment or behavior that is fair to all concerned, without bias or discrimination towards any. Health equity is likewise the experience of justice, in this case regarding access to clinical care and the achievement of medical outcomes.
Heath equity doesn’t guarantee “good” outcomes. Outcomes are only as good as medicine can make them under circumstances that medicine doesn’t necessarily control. After all, most illness is caused and complicated by genes, behavior, culture, environment and chance. Heath equity doesn’t excoriate those causes and complications. I think it’s vital to acknowledge that justice per se doesn’t make anybody well. It just levels the playing field. Outcomes depend more on the hands that individuals are dealt in life and how their cards are played.
Because of extreme economic and racial disparities, there is less health equity in the United States than in any other industrialized nation, or even in many developing nations. Health care for Americans is a privilege, not a right. The privilege entitles individuals to varying standards and quality of care based not on medical science but on social determinants like their ability to pay for diagnosis and treatment, the communities where they live, the benefits offered by their employers, the constraints imposed by their health insurers, their level of education and their race. Health care for Americans is a privilege, not a right. We get only what we pay for, not necessarily what we want or need; and not necessarily what cures or heals.
Take for example Thomas McKeller, a young African American elevator operator in Boston just after the Spanish Flu pandemic slaughtered 675,000 of his fellow Americans. By virtue of his race, socioeconomic status and lack of health insurance, he had access to inferior, substandard health care even though he was within walking distance of one of the best hospitals in the world (Massachusetts General). Contrast McKeller with John Singer Sargent, the eminent society painter whose portrait of McKeller is “humagined” at the bottom of this page. Sargent had access to state-of-the-art care in Boston or anywhere in country he needed it. Both men were Homo sapiens: specimens of the same species and endowed with the same biochemistry and physiology. Yet one was far more likely to contract, suffer and die from illness. Not because of medicine, but because of injustice. Their society lacked health equity.
Health inequities common in the early 1900s are still common a century later. This was brought into startling contrast by Covid-19, which has infected and killed our McKellers far more than our Sargents. The same was true of other maladies before the current pandemic and will likely still be true a hundred years hence. Why? The reason is mostly the disparities previously mentioned. Health care for Americans is a privilege, not a right. Health care in the United States is an industry that for sure exists to create equity, just not health equity. It exists to create the equity known as shareholder value.
That kind of equity is the experience of wealth, not justice. That kind of equity is what Donald J. Trump had in mind when he said that the murdered George Floyd was having a great day. The unemployment rate had dropped slightly and more importantly the stock market indices had inched upward. Trump’s wealth had increased, therefore Floyd can be happy in heaven. He did not die in vain.
It is easy to recoil from the obscenities of Trump in disgust, but hold on. Isn’t his exuberance what most of us feel and even say when it comes to health care? Americans have some of the worst health care and health insurance among all advanced economies, but our providers and insurers are among our most valuable corporations. The industry that produces inequitable outcomes is also fabulously wealthy. Coincidental? I don’t think so.
American health care thrives on inequity. Its business models, from hospital corporations to big pharma, earn revenue and profit from sickness and death. That being so, we must not expect “big structural change” any time soon. Health equity is a good idea, for others, but it will not make America great again.
What will? In my opinion, not the profiteers and their minions. Health equity may increase as people become smarter about their bodies, have more health literacy and health acumen, gain more control of their spend and outcomes. In other words, things may improve when folks can take better care of themselves and rely less on the medical-industrial complex.
That is the foundation of Humaginarium’s business model. Health equity is baked into our technology and philosophy. Our customers — our McKellers and Sargents — will benefit the same from what we do and no industry mugwump is ever going to change that.