Equity vs. Equality: More Bang for Our Healthcare Bucks

The moral argument for health equity is best summed up in the following quote attributed to Dr. Martin Luther King, Jr.: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Any further thought piece, blog post, or diatribe on the matter has either already been said or would be preaching to the choir.

Our healthcare system is equitable in that it does prioritize certain vulnerable populations. The majority of healthcare dollars are spent on children and the elderly, who need more attention than the rest of the population. This is equity. But what about people living in poverty? If people cannot afford their care, or are born into an unhealthy environment, don’t they have the same right to preferential treatment?

In the grand scheme of “things that should be equitable,” health is special for two reasons: 1) people die due to inaction and 2) it is one of the only such “things” where both taxpayers and private businesses are on the hook if nothing is done.

I am not an economist, but am puzzled by the following:

1)     According to the Emergency Medical Treatment and Labor Act (EMTALA) all hospitals that accept patients on Medicare (this is just about every hospital) must evaluate and stabilize any patient that walks into their emergency room. If they fail to do so they risk hefty fines and losing the ability to see Medicare patients, thus losing a large portion of their revenue.

2)     People without health insurance will often use the emergency department as their primary care physician and visit the emergency room for non-emergency reasons. Many visits for non-emergent conditions may also have been prevented by regular healthcare visits.

3)     If a patient can’t pay, and the hospital can’t get them to pay, that patient’s bill is classified as “uncompensated care.” Emergency room visits and treatment are more expensive that regular primary care, and in 2015, this cost community hospitals close to $35.2 billion (4.2% of their total expenses).

4)     This cost is offset by federal subsidies like Disproportionate Share or DSH payments from the government, i.e. taxpayer dollars.

To summarize, when poor people are not able to see a doctor outside of the emergency room, it costs hospitals and taxpayers money.

One answer is to provide people with insurance. Critics of this argument will point out that insuring low-income people with Medicaid actually increased their use of emergency departments in Oregon. The real answer, then, is not solely increased access to health insurance, but health equity.

The Healthy People 2020 report, put out by the Department of Health and Human Services defines health equity as the “attainment of the highest level of health for all people.” Here are a few more facts:

1)     The US spends more of its GDP on healthcare than any other nation but ranks 31st in life expectancy.

2)     The single biggest predictor of your life expectancy is your zip code.

In short, we are spending a lot of taxpayer money on healthcare and are not seeing the results. I want more bang for my buck!

If I was the superintendent for ten schools and noticed that the children from two of those schools kept getting infected with the flu, I’d try to find out what was happening in those two schools. Similarly, we need to find out what’s happening in those zip codes with low life expectancy and fix it.

I suspect that upon closer inspection, you’ll find that those zip codes are often in food deserts, in under-performing school districts, have high rates of environmental pollution, and could use significant improvements to their infrastructure and green space. To attain the highest level of health for all people, we need to focus on those that are least healthy. This means increasing access to healthcare for those living in poverty (the Affordable Care Act has gone a long way in doing so) and improving the social and environmental factors that lead to health disparity in poor neighborhoods. And what’s more? Investing in the health of these communities would also lead to a healthier workforce, reduce crime, and decrease spending on incarceration.

EMTALA, Medicaid, and other social programs that aim to help poor people get healthcare aren’t going away. The lack of health equity in these neighborhoods is expensive, and we are all paying for it. Demand better stewardship of your taxpayer dollars! We need to invest in these zip codes to reduce healthcare spending in the long run.

About Nebu Kolenchery

Nebu Kolenchery is a public health professional who agrees with Sir Geoffrey Vickers in that the history of public health is “the constant redefinition of the unacceptable.” He is a consultant at the Centers for Disease Control and Prevention in Atlanta, GA. (The views, opinions and positions expressed by Nebu are his alone, and do not necessarily reflect the views, opinions or positions of The Winters Group, Inc.)

One comment

  1. I never knew about the concept fo healthcare equity being focused on more vulnerable populations such as children and the elderly. My brother is working on becoming a lawyer and was talking to me about health care equity. I didn’t understand what he was talking about but your website helped clear things up.

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