Health Equity Basics
Health outcomes are not equal across Connecticut populations. State residents of color, women, people who identify as LGBTQ+, and people with disabilities have greater challenges remaining healthy. Researchers estimate that only 16% of health outcomes are related to clinical care, while socioeconomic factors and health behaviors are the majority contributors. Social determinants of health such as economic stability/poverty, food insecurity, safe housing, and education have an enormous role. Unfortunately, Connecticut’s healthcare workforce is not as diverse as the state population. But there are evidence-based solutions to address disparities and improve the health of every Connecticut resident.
Health Equity Deeper Dive
What is Health Equity?
In simple terms, health equity can be described as giving every individual the opportunity to be as healthy as possible, regardless of race, ethnicity, gender, sexual orientation, or disability status. However, this should not be confused with equality. It’s critical to recognize the unique and different needs or resources a person or group of people needs to thrive. Health equity is not simply offering all individuals the same opportunities but working to eliminate the disparities within a population to allow everyone to be as healthy as possible.
For example, only focusing on health equality would mean that every patient with a disease is given the same prescription. Health equity would focus on ensuring every patient with the disease gets the prescription that works for them and has the same resources/opportunities to both receive the prescription and understands how to take it properly. In this scenario, health equity focuses on the need for each patient to be able to afford the prescription, have appropriate transportation to pick up the prescription, access to the health care provider’s office, and get understandable instructions about how and when to take the prescription, in their language.
The groups most vulnerable to inequities are people of color, women, people who identify as LBGTQ+, and those living with disabilities. Connecticut is not immune to disparities. While disparities are harmful to individual and community health, they are also costly. It’s estimated that disparities cause an extra $384 million in hospital costs for Black state residents and another $121 million for Connecticut Hispanics.
Connecticut’s State Health Improvement Plan (SHIP) called Healthy Connecticut 2025, is focused on improving equity and eliminating structural racism. The plan is built on four Social Drivers of Health. The goals, objectives, and strategies are listed in the table below.
Race and ethnicity
Connecticut is not immune to significant racial and ethnic health disparities including higher rates of asthma, diabetes, cancer, infant mortality, and uninsurance.
In Connecticut in 2019, the Black infant mortality rate was nearly two and a half times greater than for whites. This means that Black infants in Connecticut were two and a half times more likely to die than white infants. Black women in Connecticut have less access to optimal prenatal care and higher rates of uncontrolled chronic diseases put both Black mothers and infants at risk leading to higher rates of mortality in Connecticut.
In addition, Black Connecticut residents are more than twice as likely to die from diabetes than whites, according to data from 2020. Furthermore, Black residents were three times more likely to undergo a diabetes-related lower-extremity-amputation than whites, which is usually preventable with adequate medical care. Among Hispanics, the rate of enduring a diabetes-related lower-extremity-amputation is just over two times greater than whites in Connecticut.
Hispanic children and teens in Connecticut are four and a half times more likely than whites to visit an emergency room for asthma, and over three times more likely to be hospitalized. Hispanic and Black state residents are twice as likely to have diabetes and more likely to have serious complications of the disease.
The burden of disparities doesn’t fall only on Connecticut residents of color. It’s estimated that disparities cause an extra $384 million in hospital costs for Black state residents and another $121 million for Connecticut Hispanics. We all pay these costs. Experts estimate that inequity currently costs the US health system $320 billion each year. Those costs are growing and could reach $1 trillion annually by 2040.
LGBTQ+
A 2022 community needs assessment of Connecticut’s LGBTQ+ community for the Department of Public Health found that sixteen percent of survey respondents reported being refused healthcare services and 15% refused behavioral healthcare because of their LGBTQ+ identity. Two thirds had concerns about accessing healthcare, including that care would not be LGBTQ+ friendly, providers and staff would not be trained in their needs, and not knowing where to access services. Challenges noted in the survey included being misgendered or “deadnamed,” harassed, or unnecessarily questioned by providers who lacked an understanding of LGBTQ+-related health needs, and stigma surrounding STD/STI-related healthcare.
Disabilities
In Connecticut, 1 in 5 adults, or 21% of Connecticut’s population has a disability. People with disabilities face high rates of health inequities. For example, Connecticut residents with one or more disabilities are more than three times as likely to have depression and more than twice as likely to have heart disease and diabetes when compared to Connecticut residents without a disability.
People with disabilities are less likely to get primary, preventive and maintenance care, with costly consequences.
Compared to Americans without disabilities, adults with intellectual and developmental disabilities were five times more likely to be in poor health and half as likely to get a check-up. They have lower rates of blood pressure checks, flu shots, or screens for cancer, cholesterol, vision, or hearing. They are also four times less likely to get physical activity and more likely to be obese.
Studies have found resistance among physicians to caring for patients with developmental disabilities. Researchers found structural and financial barriers, as well as poor information and biases, that affected their willingness to care for patients with disabilities. Physicians are overwhelmed, both in general and by legal requirements. They often lack knowledge and feel unqualified to care for patients with disabilities. One noted that the usual fifteen-minute visit is “absolutely ridiculous”. People with disabilities are more likely to report inadequate patient-physician communication that affects their access to care and health outcomes.
Gender
In 2021, women in Connecticut were more likely to be in poor physical and mental health than men (10.1% vs. 7.6%, and 15.2% vs. 10.2%). In 2019, Connecticut women had the fourth highest rate of breast cancer among states.
A significant inequity that directly affects health is the gender wage gap. Women in Connecticut earn 84 cents for every dollar paid to men. Even more sobering, Latina and Black women in Connecticut make only 47 and 58 cents for every dollar paid to men, respectively. Because they earn less than men, women often face more difficulty paying for healthcare bills, prescriptions, and health products, creating a health inequity.
What can cause health inequities?
While there is not a single answer, social determinants of health are an important factor.
Social determinants of health (SDOH) are the conditions in the environment where people live, work, play, learn, and age that affect health outcomes. SDOHs reveal the interrelated aspects of health inequities that lead to poor health outcomes. Recognizing and working to improve SDOHs are very important because an individual’s overall health is determined far more by their social determinants rather than the medical care they receive. Researchers estimate that medical care contributes 16% to our health outcomes while socioeconomic factors contribute 47%, health behaviors 34%, and the physical environment 3%.
What are Social Determinants of Health?
Social determinants of health span a wide continuum of overlapping factors, including economic stability, food security, housing, and education.
Economic stability/Poverty
People with financial security/steady employment are more likely to be healthy and less likely to live in poverty. Those who are financially insecure, particularly those in poverty, are much more likely to suffer from food and housing insecurities which consequently lead to higher incidences of diabetes, cancer, and poor birth outcomes. Moreover, people with low incomes, financial insecurity or who live in poverty suffer from higher rates of depression which is associated with further negative health outcomes such as greater disease burden, longer duration of illness, disability, and suicide. Without economic stability, people may struggle to afford health care, afford transportation to access health care, cannot take time off work to receive care, cannot afford healthy or nutritious foods, lack resources to safely exercise, or cannot afford to live in a healthy environment.
In 2019 in Connecticut, the white poverty rate was 5.8% while the Black and Hispanic poverty rates were 18.4% and 22%, respectively. Economic instability directly impacts health equity and overall health outcomes.
Food Insecurity
Food insecurity is another SDOH described as an individual being unable to afford food at least once in the last 12 months. Good nutrition is critical for the body to dedicate energy to healing from an illness, managing chronic diseases, strengthening the body’s immune responses, and overall health. Unsurprisingly, individuals with lower incomes and who lack economic stability suffer worse food insecurities in Connecticut. For households with very low incomes, the Supplemental Nutrition Assistance Program (SNAP) helps to cover some costs of food with subsidies estimated to be $1.86 per meal. Unfortunately, in Connecticut, the estimated cost of a meal is 40 to 50% higher than the SNAP per-meal benefit.
In Connecticut, 23% of Black adults and 28% of Latino adults experienced food insecurities, compared to just 10% of white adults. Consequently, Black and Latino adults in Connecticut are more likely to have poor nutrition and lack access to nutritious foods, further impacting health outcomes.
Housing and the Physical Environment
Another SDOH with profound impact on overall health is the home and physical environment. Barriers to affordable and safe housing can negatively affect health by exposing individuals to harmful environmental conditions in the home or neighborhood and limiting available resources that can be used for food, healthcare, or education. When families or individuals have to spend a large part of their income on housing (more than 30%), this can exacerbate stress levels and mental health illnesses and is linked to an increased risk of disease because there isn’t money for healthy foods or healthcare.
In Connecticut, 34.6% of residents report spending more than 30% of their income on housing. Among Connecticut residents, 44.5% of Black residents, 45% of Hispanic or Latino residents, and only 32.6% of white residents reported spending more than 30% of their income on housing.
Women in Connecticut experience a much greater cost burden for housing when compared to men. For example, 50% of white women who rent experience housing cost burdens, compared to only 39% of white men who rent housing in Connecticut. Moreover, 62% of Black women and 63% of Latino women who rent housing experience housing cost burdens compared to only 50% and 52% of Black and Latino men, respectively.
Higher housing cost burdens decrease the financial resources available to spend on healthcare, food, or education.
Additionally, the physical environment also is a social determinant of health that can impact health outcomes. For example, in Connecticut, children who live in urban areas experienced a six times greater rate of lead poisoning (4.9%) than children in suburban communities (0.8%). Lead poisoning in early childhood, when rapid neurological development takes place, is a serious danger to a growing child with profound effects on health outcomes. Access to neighborhood amenities such as parks, bike trails, access to gyms or recreational facilities is associated with improved physical and mental health, as well as feeling a sense of belonging. In Connecticut, residents in rural locations were less likely to have access to these resources, while white adults, residents of suburban or wealthy towns, and adults with higher levels of income and education were more likely to report access to these resources.
Education Access and Quality
People with higher levels of education are likely to live longer and be healthier. Children from low-income families or who have disabilities are more likely to struggle with math and reading and are less likely to graduate from high school or go to college. These problems can lead to difficulty obtaining safe and stable employment with health insurance and developing health problems such as heart disease, diabetes, and depression. Additionally, children who live in poverty often attend poorer-performing schools, and many families in poverty cannot afford to send their children to college. Children who live in poverty experience stress that can affect brain development, making it even more difficult for them to perform well in school.
In Connecticut, children with Special Education (SPED) or English Language Learner (ELL) designations have much lower four-year high school graduation rates. For example, children with SPED designations have a graduation rate of 67% compared to non-SPED students, who graduate with a rate of 92%. Similarly, ELL students graduate at a rate of 68%, while non-ELL students graduate at a rate of 89% in Connecticut.
People with higher levels of education are more likely to be healthy and live longer. Students from low-income backgrounds, who have disabilities, or who require special learning programs experience poorer graduation rates and attend poorer-performing schools, leading to further health inequities in adulthood.
Is Connecticut’s healthcare workforce diverse?
There is ample evidence that diversity among healthcare providers supports improving equity for underserved populations. Unfortunately, Connecticut’s healthcare workforce does not reflect Connecticut’s population in race and ethnicity. Whites are over-represented while Blacks and Hispanics are under-represented among Physicians, Advanced Practice Nurses, Physician Assistants, Registered Nurses, and Dentists.
Source: Area Health Resources Files, HRSA
Researchers have identified policy and practice solutions that can help diversify the workforce. Recommendations cross educational, career, financial, social, and institutional supports.
How can healthcare planning promote equity?
Disparities can be unintentionally embedded in policymaking. Without conscious and vigorous effort to address biases, those disparities will be perpetuated into the future.
For 2023, the Connecticut Health Foundation has developed recommendations for policymakers to promote Better Health for All, including underserved communities. The recommendations include expanding coverage, care coordination to promote prevention and manage chronic health problems, engage Community Health Workers in their communities to improve health, and take care in unwinding COVID protections and expansions of coverage to mitigate harm.
There is a special concern that, as more payers use health technology assessments (HTAs) to promote value in the healthcare system, that health equity be incorporated into the methods to ensure underserved communities have fair access to innovative new treatments. HTAs are evidence-based evaluations of healthcare treatments for clinical effectiveness and fair pricing. HTAs ensure the system rewards innovations that significantly improve health with fair prices.
Consulting with experts and patient advocates, the Institute for Clinical and Economic Review (ICER) has developed standards for entities assessing clinical effectiveness and fair pricing, in the US and beyond, to promote health equity for disadvantaged groups. The standards were developed in consultation with providers, patient advocates for underserved communities, bioscience, insurer, and academic sources. ICER is the US leader in assessing treatments for value. ICER’s reports are used by most government and private payers in developing coverage policies and fair prices.
The standards include:
- selecting treatments for study
- engaging patients in the process
- evaluating the diversity of clinical trial participants
- analyzing the data by subpopulations
- measuring opportunities to reduce disparities
- promoting equity through quantitative comparative effectiveness analysis, and
- promoting equity through deliberative methods
Solutions for social determinants of health
While there is much to learn, there are policy options that can improve equity. Proven public health interventions are key. There is a great deal of research identifying public health interventions that are proven to reduce inequities, improve health and lower total healthcare costs. Among the most effective are tobacco control, food safety, reducing infections in healthcare settings, motor vehicle injuries, teen pregnancy, and improving nutrition, physical activity, and lowering obesity rates. Searchable databases have made it easy to prioritize initiatives and identify best practices. There is help for state policymakers in using that research to implement proven interventions.
Connecticut’s Department of Public Health has also created a Health Equity Toolkit for local public health departments and other partners with resources and practical tools to help understand health equity and include it in their work. Connecticut’s Medicaid/HUSKY program also has information and resources for providers including assessments and other tools to identify and address the drivers of inequity for their patients.
Written by Haley Magnetta, PA-C, MPAS, DMSc, Stefanie Generao, APRN, DNP, and Ellen Andrews, PhD.