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Health equity is declining in the United States

July 11, 2019

Topics: Quote of the Day

By Frederick J. Zimmerman, PhD, Nathaniel W. Anderson, BA, of the Jonathan and Karin Fielding School of Public Health, Department of Health Policy & Management, University of California, Los Angeles
JAMA Network Open, June 28, 2019


Importance: Health equity is an often-cited goal of public health, included among the 4 overarching goals of the Department of Health and Human Services’ Healthy People 2020. Yet it is difficult to find summary assessments of national progress toward this goal.

Objectives: To identify variation in several measures of health equity from 1993 to 2017 in the United States and to test whether there are significant time trends.

Design, Setting, and Participants: Survey study using 25 years of data, from January 1, 1993, to December 31, 2017, from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System to assess trends in health equity and health justice by race/ethnicity, sex, and income in 3 categories by year.

Main Outcomes and Measures: Health equity was assessed separately for each of 2 health constructs: healthy days—the average of physical and mental healthy days over the previous 30 days—and general health in 5 categories, rescaled to approximate a continuous variable. For each health construct, average health was calculated along with 4 measures of health equity: disparities across 3 income groups; black-white disparities; health justice—a measure of the correlation of health outcomes with income, race/ethnicity and sex; and a summary health equity metric.

Results: Among the 5 456 006 respondents, the mean (SD) age was 44.5 (12.7) years; 3 178 688 (58.3%) were female; 4 163 945 (76.3%) were non-Latinx white; 474 855 (8.7%) were non-Latinx black; 419 542 (7.7%) were Latinx; and 397 664 (7.3%) were of other race/ethnicity. The final sample included 5 456 006 respondents for self-reported health and 5 349 527 respondents for healthy days. During the 25-year period, the black-white gap showed significant improvement (year coefficient: healthy days, 0.021; 97.5% CI, 0.012 to 0.029; P < .001; self-reported health, 0.030; 97.5% CI, 0.025 to 0.035; P < .001). The health equity metric for self-reported health showed no significant trend. For healthy days, the Health Equity Metric declined over time (year coefficient: healthy days, −0.025; 97.5% CI, −0.033 to −0.017; P < .001). Health justice declined over time (year coefficient: healthy days, −0.045; 97.5% CI, −0.053 to −0.038; P < .001; self-reported health, −0.035; 97.5% CI, −0.046 to−0.023; P < .001), and income disparities worsened (year coefficient: healthy days, −0.060; 97.5% CI, −0.076 to −0.044; P < .001; self-reported health, −0.029; 97.5% CI, −0.046 to −0.012; P < .001).

Conclusions and Relevance: Results of this analysis suggest that there has been a clear lack of progress on health equity during the past 25 years in the United States. Achieving widely shared goals of improving health equity will require greater effort from public health policy makers, along with their partners in medicine and the sectors that contribute to the social determinants of health.

From the Discussion

The results of this study show a worrisome lack of progress on health equity during the past 25 years in the United States. Although there are some differences across conceptualizations of health equity, and small differences across the 2 concepts of overall health, the overall pattern is one of stagnation mixed with unambiguous decline.


Improving health equity often figures as an important goal for communities, thought leaders, and policy makers in public health. Yet, this analysis suggests that across the past 25 years, the promise of improving health equity has not been met. Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve. Performance tracking of health equity may help to keep policy makers accountable to making the necessary changes.



By Don McCanne, M.D.

The authors conclude that the overall pattern of health equity during the past 25 years in the United States is one of “stagnation mixed with unambiguous decline.”

Shocking! Shocking! Absolutely shocking!

How can anyone call this a great nation when we tolerate such injustices?

Progress will not come from the private sector. There is an urgent need for the enactment and implementation of new public policies if we ever hope to reverse these injustices.

Although there is much to be done, we have before us legislation that would would take a giant step forward in improving health equity, and that is the Medicare for All Act of 2019 in the House (Jayapal) and in the Senate (Sanders). The features of this single payer model of health care would dramatically advance health equity because it would automatically include absolutely everyone in a system financed equitably through progressive taxes.

Yet the House is bogged down in protecting the private insurance industry instead – a source of much of the inequity in health care – and the Senate is going to do all they can to prevent the government from becoming involved.

The authors state, “Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve.” Let’s start with enacting single payer improved Medicare for all. If our politicians won’t do that, then we should replace them. Or shall we just abandon our claim of being a great nation?

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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