Government decision-making is one of the world’s great exercises in managing competing interests, and there are few political issues where this has higher stakes than in the healthcare debates. In the broadest sense, the competing ideas are individual choice (as conferred by freedom-of-markets) and the health-as-a-human-right canon.
Within these larger debates are sub-conflicts on both sides of the left-right axis. One that has arisen in recent years involves differences between the “health access” and “health equity” movements. These factions are part of one political genus comprised of intellectuals, practitioners, and activists who prioritize justice and equality in healthcare, but with different emphases.
Health access focuses on the delivery of healthcare services to people, and especially disenfranchised populations. Its central dogma points to data on the low availability of healthcare services (preventative and other) in many parts of the country and its effect on health outcomes. Other health access arms delve further into quality of care, and emphasize that it’s not only the amount but also the effectiveness of healthcare services that drives health outcomes.
The health equity movement shares the same concerns, but adopts a more granular view of healthcare problems, with a focus on why certain populations are affected by poor health outcomes. It includes its sister faction, health disparities, an early 2000s intellectual movement that emphasized how race, ethnicity, class, gender, geography and other factors can craft the health status of a population.
The crux of the health access argument can be captured in broad patterns and data sets, while health equity arguments are rooted in detailed case studies and narratives. Both have strengths and weaknesses. The vision that guides the health access cause is clear, applies broadly across settings and circumstances, and has reasonable political and policy goals. It suffers, however, in understanding the complexities of the American context. The Health equity movement has unpacked several startling societal paradoxes about human health, and has taught us about the power of interactions between human health and society. The health equity movement is often criticized for how its proposed solutions can sound nebulous or unrealistic (e.g. the end of racism, classism and sexism).
The health access vs. health equity debate existed in spirit for many years, but became more visible after the 2010 passage of the Affordable Care Act (ACA). The ACA is understood to be a triumph of the political left, as its moral backbone (that the large number of uninsured Americans is a serious problem requiring government intervention) resembles the health-as-a-human-right moral core of single payer healthcare systems.
Though the leftist spirit of the ACA has been overstated, it has successfully emboldened healthcare activists and scholars around health justice issues. It has also breathed financial life into the many organizations that work for these causes.
Philanthropic foundations issue new calls for proposals; government agencies discuss starting initiatives; academic institutions hire faculty to teach courses to a new generation of healthcare experts and practitioners. Time and funds are limited, however, and these institutions need to know where to get the best leftist bang for their buck. This is the limited resource that fosters a competitive ecology.
If there were ever an honest discourse around the intellectual backbone of this debate (which there hasn’t been), we would find that the two are far less dichotomous than they appear. As an example, we’ll use a well-studied problem: the obesity epidemic among African American women.
In the case of obesity among African-American women, to care about disparities in health outcomes is to understand that a dearth of available services, competent professionals, and educational resources is absolutely necessary for improving outcomes. The reason that access bumps heads with equity in this example is because of a misunderstanding of necessity vs. sufficiency: improved access to healthcare services is absolutely necessary for improvements in obesity outcomes. It is not, however, sufficient to close the gap. To fix the entire problem, we need to address the forces that influence access to health food, the mentalities that lead to poor dietary decisions, and structures that create stressful living conditions for African-American women.
In the case of African-American women and obesity, the answer to the question (access vs. equity) of where to focus our attention on items that are actionable, can lead to immediate changes in health outcomes regardless of whether or not they fall in the health access or health equity realm.
For example, the war against Big Food is a health equity issue that can work synergistically with health access reforms. Fighting against the legal basis for companies selling toxic food in low-income communities doesn’t run counter to the idea that the federal government should invest in more primary healthcare clinics. The two, alternatively, work in concert: Big Food operates in the very communities where we see the largest ethnic and class-based health disparities many of which have a dearth of primary care providers. By limiting sugar content in soft drinks and improving health education programming, you have hit the obesity and diabetes problems on two fronts.
Like many debates, this resolution is easier to argue than to execute. I would suggest, however, that it must be openly discussed, and argued, before it can be executed. My longer-term hope is that the newfound visibility of healthcare in public dialogue and the greater number of venues to discuss the issue will quell the professional territoriality that typifies health access vs. health equity, and create a unified movement that continues the eternal march to improve human health.