Health equity
Health is influenced by where people live, work, learn, and play.
Inequities in housing, education, income, employment, transportation, food access, etc., deeply affect health outcomes.
Health care accounts for only ~10%–20% of modifiable contributors to health outcomes.
Racial/ethnic minority and low-income populations are disproportionately impacted due to structural and historical inequities.
CDC’s Five Equity-Centered Principles
- Prioritize equity: Make equity a goal from the start.
- Engage communities: Center the voices of impacted populations.
- Consider context: Recognize systemic inequities that shape how messages are received.
- Address power imbalances: Avoid deficit framing and dehumanizing language.
- Reflect and adopt: Reassess messaging strategies and correct mistakes.
Health injustice stems from structural racism, disinvestment, and historical trauma.
Clinicians can
- Recognize bias in clinical decision-making (e.g., race-based algorithms).
- Advocate for institutional reform (e.g., equity-focused quality metrics).
- Build trusting relationships with marginalized patients and communities.
- Commit to lifelong learning about equity and anti-racism.
Socioeconomic status and health disparities
Housing as a SDoH
There is strong evidence characterizing housing’s relationship to health. Housing stability, quality, safety, and affordability all affect health outcomes, as do physical and social characteristics of neighborhoods.
- Chronic stress from frequent moves or eviction increases allostatic load and is associated with depression, anxiety, and poor chronic disease control. As well as poor academic outcomes in children.
- More on adverse childhood experiences (ACEs) and housing disruption as trauma later in this module.
- Housing First model: Permanent housing plus wraparound services has been shown to reduce acute care use and improve mental health outcomes for people experiencing homelessness.
- By providing stable housing as a foundation, individuals can better access and engage with voluntary support services, leading to improved well-being and reduced reliance on emergency services.
- Permanent Supportive Housing with Housing First to Reduce Homelessness and Promote Health among Homeless Populations with Disability: A Community Guide Systematic Review.
- Supportive Housing (with ancillary services).
- Other strategies:
- Rental subsidies.
- Eviction legal assistance.
- Energy assistance (e.g. LIHEAP).
- Multi-sector collaborations:
- Health + Housing + Legal Aid + Local Government.
- PubMed summary of conceptual models in housing-health.
- Housing and Health.
- Poor housing quality and inadequate conditions can contribute to negative health outcomes, including chronic disease and injury.
- Subtopics:
- Asthma triggers:
- Dampness leading to mold growth.
- Poor ventilation.
- Asbestos.
- Dust mites.
- Pests (cockroaches and rodents).
- Injury risk:
- Poor lighting.
- Broken stairs.
- Slippery surfaces.
- Exposed heating sources.
- Unsafe neighborhoods.
- Developmental Delays:
- Lead exposure, often from deteriorating lead-based paint in older homes.
- Can irreversibly affect a child’s brain and nervous system development, potentially leading to neurological delays and learning disabilities.
- Asthma triggers:
- High housing cost burdens disrupt the ability to afford health care, medications, nutrition, and stable environments.
- Cost-burdened households = spending > 30% of income on housing.
- When housing costs exceed this threshold, families often sacrifice:
- Prescription medication.
- Nutritious food.
- Preventative or primary care visits.
- Financial stress leads to chronic toxic stress and exacerbates mental and physical health issues.
- Cost-burdened individuals show higher rates of:
- Hypertension.
- Depression and anxiety.
- Delayed or foregone medical care.
- Families in unstable or unaffordable housing report poorer management of diabetes, asthma, and other chronic conditions.
- Public Health Interventions.
- Expand eligibility and funding for rental assistance programs
- Promote “Medicaid-housing partnerships” where states use Medicaid waivers to support housing-related services
- Screen for housing cost burden in primary care using tools like PRAPARE or AHC-HRSN
- Residual-income approach to better assess affordability includes:
-
- Household’s total income and subtracts necessary expenses like food, transportation, and healthcare, leaving the remaining income available for housing.
- Stone, M., Burke, T., Ralston, L. (2011) The Residual Income Approach to Housing Affordability: The Theory and the Practice. University of Massachusetts Boston.
Where you live affects access to:
- Health-promoting environments (parks, grocery stores, safe walking areas).
- Employment, education, and social capital.
- Clean air, water, and safe housing.
Structural racism (e.g., redlining, zoning laws) has led to racial and economic segregation of neighborhoods.
- Redlining is a discriminatory practice where financial institutions deny services like mortgages, loans, and insurance to residents of certain neighborhoods, often based on race or ethnicity, and/or because they live in an area deemed to be a poor financial risk. This practice originated in the 1930s with government maps (created by the Home Owners’ Loan Corporation [HOLC]) that designated areas as “risky investments” based on the racial makeup of residents, with areas deemed risky being marked in red.
Residents in historically redlined neighborhoods experience:
- Higher rates of asthma, cardiovascular disease, and infant mortality.
- Fewer healthcare facilities and green spaces.
- Greater exposure to environmental hazards like air pollution and heat islands.
- Heat islands, also known as urban heat islands, are areas within a city that experience higher temperatures than surrounding rural areas. This phenomenon is primarily caused by the concentration of buildings, roads, and other infrastructure, which absorb and re-emit more solar heat than natural landscapes.
Tools and Maps
- Area Deprivation Index (ADI): Ranks neighborhoods by socioeconomic disadvantage.
- CDC’s Social Vulnerability Index (SVI): Identifies communities at higher risk of poor outcomes in disasters and health emergencies.
Public Health Interventions.
- Zoning reform to encourage mixed-income housing and reduce concentrated poverty.
- Investments in safe, walkable infrastructure.
- Community-based programs for environmental cleanup and violence prevention.
| Intervention | Health impact | Cost impact | Equity consideration |
|---|---|---|---|
|
Housing first |
↓ ER use, ↓ mortality
|
↓ Public spending
|
Prioritizes chronically homeless
|
|
Lead abatement |
↓ Neurotoxicity, ↑ IQ |
High ROI long-term |
Targets low-income communities |
|
Eviction prevention |
↓ Mental health crises |
↓ Downstream service use |
Addresses structural inequity |
|
Weatherization |
↓ Respiratory illness |
↓ Energy bills |
Can reduce health disparities |
Reflection questions
- What role can clinicians play in housing advocacy? (e.g., screening, community referrals, public policy engagement)
- How do housing interventions compare to traditional clinical interventions in ROI and outcomes?
- What ethical responsibilities do physicians have in addressing upstream social determinants?
- Describe a real-world patient scenario that you’ve seen in which housing affected health.
Food insecurity and geographic location
The Lancet: Deeply entrenched racial and geographic health disparities in the USA have increased over the last two decades – as life expectancy gap widens to 20 years.
Rural Health Disparities.
CDC: About Rural Health.
definition
Food insecurity refers to limited or uncertain access to adequate food due to financial or other resource constraints.
The USDA classifies food insecurity as:
- Low food security: Reduced quality, variety, or desirability of diet.
- Very low food security: Disrupted eating patterns and reduced food intake.
- USDA: Food Access Research Atlas.
- Associated with higher rates of obesity, type 2 diabetes, hypertension, cardiovascular disease, and cancer.
- Leads to dietary compromises such as choosing calorie-dense, nutrient-poor food due to cost and availability.
- Chronic stress from food insecurity worsens inflammatory responses and mental health, contributing to allostatic load and disease.
Key Terms
- Food deserts: Areas with limited access to affordable and nutritious food.
- Food swamps: Areas with high-density of fast food and convenience stores relative to healthy food retailers.
Structural Factors
- Redlining and disinvestment in communities of color.
- Zoning policies favoring fast-food over grocery development.
- Lack of transportation or walkability.
Health disparities associated with ACEs and weight management
Statistics
- At least 5 of the top 10 leading causes of death are associated with ACEs.
- About 64% of adults in the United States reported that they had experienced at least one type of ACE before age 18.
- Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs before age 18.
- Three in four high school students reported experiencing one or more ACEs, and one in five experienced four or more ACEs.
- “ACEs that were most common among high school students were emotional abuse, physical abuse, and living in a household affected by poor mental health or substance abuse.” (CDC)
- “Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs.” (CDC)
- Preventing ACEs could reduce:
- Suicide attempts among high school students by as much as 89%.
- Prescription pain medication misuse by as much as 84%.
- Persistent feelings of sadness or hopelessness by as much as 66%.
- The number of adults with depression by as much as 44%.
- “ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work.” (CDC)
- “While all children are at risk of ACEs, numerous studies show inequities in such experiences which are linked to the historical, social, and economic environments in which some families live.” (CDC)
Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice. JAMA Network.
Association of adverse childhood experiences (ACEs) with obesity and underweight in children. PubMed.
Diet quality and obesity in senior
Choi YJ, Crimmins EM, Ailshire JA. Food insecurity, food environments, and disparities in diet quality and obesity in a nationally representative sample of community-dwelling older Americans. Prev Med Rep. 2022 Jul 20;29:101912. doi: 10.1016/j.pmedr.2022.101912. PMID: 35911578; PMCID: PMC9326331.
Institute of Medicine (U.S.) Committee on an Evidence Framework for Obesity Prevention Decision Making; Kumanyika SK, Parker L, Sim LJ, editors. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington (DC): National Academies Press (U.S.); 2010.
Structural racism creates inequities in food access
Decades of discriminatory housing, lending, and economic policies have led to the racialized geography of food insecurity.
Communities of color are more likely to live in areas without full-service grocery stores and face targeted marketing of unhealthy products.
Solutions must center equity and community voice—not just individual behavior change.
Statistics
- One in Eight U.S. households experienced food insecurity in 2022.
- Black and Hispanic households experience food insecurity at 2×–3× rate of white households.
- Food insecurity increases the risk of hospitalization and poor disease control in chronic illness.
IHME Report about racial and geographic health disparities.
Mechanistic pathways
Economic constraints lead to reduced access to fresh foods and reliance on cheap, processed options.
Psychosocial stress contributes to cortisol dysregulation, inflammation, and anxiety.
Limited physical access results in longer travel times and transportation barriers.
Time scarcity (working poor) → Less time to cook, shop, or eat regularly.
Cultural mismatch in resources → Available food doesn’t align with cultural needs and/or preferences.
Interventions at multiple levels
- Nutrition education.
- Food insecurity screening.
- SNAP/WIC enrollment.
- Mobile markets.
- Urban agriculture.
- Farmers’ markets.
- Corner store programs.
- Hospital-based food pantries.
- Food prescription programs.
- Tax incentives for grocery stores.
- Zoning reform.
- Minimum wage policies.
Cognitive Health in Older Adults
BMC Medicine (2025). Disparities in Neighborhood Food Environment and Cognitive Decline.
Urban older adults living in low-income and low-access neighborhoods experienced significantly accelerated cognitive decline (β ≈ –0.19/year) compared to peers in better nourished environments.
Geographic Variation and Cardiometabolic Outcomes
Joseph et al. (2025). Geospatial Analysis of Food Insecurity and Adverse Human Health Outcomes in the U.S.
Found strong positive associations between high food insecurity and higher rates of diabetes (IRR ≈ 1.20–1.23) and cardiovascular disease (IRR ≈ 1.03–1.09), especially concentrated in the South.
Food Is Medicine Movement
Time / JAMA coverage (2024). Food Is Medicine.
National expansion of produce-prescription programs integrated into Medicaid/Medicare Advantage, with emerging evidence showing improved diet and chronic disease outcomes.
Reflection questions
- How would you identify food insecurity in your clinical practice?
- What is your role as a future physician in addressing structural barriers to food access?
- What makes an intervention equity-focused versus well-intentioned but insufficient?
- How does food insecurity intersect with other social determinants (housing, income, education)?
Race, ethnicity, and health disparities
The 2023 review by Macias Konstantopoulos et al. clarifies that race is socially constructed yet strongly associated with health disparities due to systemic factors—not genetics.
- Disparities arise from structural racism and inequitable systems.
- Historically, misattributed health differences to “biological” racial traits, but such theories have been thoroughly debunked.
Black, Hispanic, American Indian/Alaska Native (AIAN), and Native Hawaiian/Pacific Islander (NHPI) groups fare worse than White counterparts in most health measures; while Asians often fare better—but data may mask subgroup inequities. Source: KFF report.
Life expectancy
- Between 2019–2021:
- Life expectancy dropped by 6.6 years for AIAN. 4.2 years for Hispanic, and 4.0 years for Black people—far greater than the 2.4-year decline for White people.
- As of 2022, life expectancy is lowest among AIAN (67.9 yrs) and Black (72.8 yrs) people; highest among Asians (84.5 yrs).
Self-reported health status
- Fair or poor health:
- AIAN 29%.
- Hispanic 23%.
- Black 21%.
- White 16%.
- Asian 10%.
Health coverage and access to care
- Uninsured rates (under 65):
- AIAN 18.7%.
- Hispanic 17.9%.
- NHPI 12.8%.
- Black 9.7%.
- White 6.5%.
- Despite ACA gains, coverage disparities persist and even widen, especially in non‐Medicaid expansion states.
- Children’s coverage disparities persist: AIAN children ~12.7% uninsured vs. 4.0% for White children.
Discrimination and bias in health care settings
- 29% of Whites reported worrying about appearance before appointments vs. 55% of Black, ~50% of AIAN/Hispanic, and ~40% of Asian people.
- A quarter of Black adults say they experienced race-based negative treatment; 22% of Black mothers reported being denied needed pain medication.
Maternal and infant health outcomes
- Pregnancy-related mortality is highest for NHPI (62.8 per 100 k), Black (49.5), AIAN (32), and lowest for Hispanic (11.6) women.
- Disparities stem from structural racism, healthcare access differences, and hospital quality.
Pain management and emergency department treatment
- Sickle Cell Disease.
Chronic disease burden
- Hypertension.
- Diabetes.
- Obesity.
Infectious diseases
- Covid-19.
- HIV/AIDS.
- Environment and rural access.
SDoH: Higher poverty rates, crowded housing, and environmental exposures in communities of color.
Insurance and access: Higher uninsured rates among AIAN, Hispanic, and Black adults limit preventive and acute care.
Discrimination and bias: Widespread interpersonal and institutional discrimination in healthcare settings negatively impact health-seeking behavior and outcomes.
Systemic under-resourcing: Safety-net facilities serving BIPOC communities are often underfunded, reinforcing inequities.
At the clinical level
- Incorporate stratified metrics (e.g., coverage, immunization, wait times) into performance dashboards.
- Use evidence-based checklists and bias-awareness tools—especially in maternal and emergency care.
- Increase workforce diversity to improve communication and cultural safety.
At the system and policy level
- Expand Medicaid in holdout states to reduce coverage gaps.
- Strengthen Federally Qualified Health Centers (FQHCs) to boost community-based care access.
- Implement anti-racism training and enforce reporting of race-based outcomes.
- Launch community-based programs for preventative health (e.g., flu, HIV screenings), prioritizing underserved ZIP codes.
- Health inequities are multi-layered, requiring both clinical-level vigilance and structural reforms.
- Sustained progress depends on commitment through training, policy, research, and community engagement.
- Evidence-based data helps quantify and target interventions.
- Equity-focused training, resource redistribution, and policy change are essential to systemic improvement.
Gender and health disparities
Watch the following video (~4.35 minutes).
- LGBTQ+ adults are younger but more likely to report poor/fair health (25% vs. 18%).
- Higher rates of disability (25% vs. 16%).
- More reliant on Medicaid (22% vs. 13%), less likely to have major employer coverage.
- Less likely to have a regular health provider (72% vs. 77%).
- Higher use of telehealth, particularly for mental health (63% vs. 53%).
- Delayed or skipped care more frequently due to discrimination or cost.
- 67% report needing mental health care in past year; 35% had unmet needs.
- Higher incidence of anxiety, depression, and substance use—often untreated.
- 45% report experiencing negative interactions:
- Dismissiveness.
- Assumptions.
- Denial of care.
- Nearly 20% fear being judged or mistreated by providers.
Disparities linked to:
Structural marginalization refers to the way that societal systems, institutions, and policies are organized in ways that disadvantage certain groups—often invisibly or by default.
- Health systems design: Many EHRs and clinic forms assume binary gender and heterosexual relationships, forcing patients to either misrepresent themselves, or out themselves in potentially unsafe settings.
- Insurance and medicaid policy: Gender-affirming care may be explicitly excluded from coverage in some states, even when medically necessary and supported by guidelines (e.g., hormone therapy, surgeries).
- Legal and policy environment: Anti-LGBTQ+ laws (e.g., restrictions on transgender care for youth) can foster hostile environments that make individuals less likely to seek care—even when it’s available.
- Workforce exclusion: Lack of openly LGBTQ+ providers and undertraining of clinicians perpetuate environments where patients expect mistreatment, contributing to underutilization and poorer health outcomes.
- The Biden administration’s attempt to reinstate gender identity protections under Section 1557 (ACA) marked a significant step in combating transgender discrimination—but these regulations are currently delayed by courts, limiting enforcement of nondiscrimination in federally funded health programs.
- Even when protections exist, systemic implementation lags. Providers and insurers often lack the infrastructure or buy-in to comply fully, limiting the real-world efficacy of these rules.
- Primary care models remain underdeveloped in gender-sensitive modalities: EHRs still commonly force binary gender assumptions, and screening protocols lack integration of gender identity and sexual orientation (SOGI) data.
Minority Stress Theory, developed by psychologist Ilan Meyer, posits that sexual and gender minorities experience chronic social stress stemming from their stigmatized status, which negatively affects their health over time.
- Distal stressors:
- Overt discrimination.
- Harassment.
- Rejection (e.g., being misgendered, denied care, or mocked by providers).
- Proximal stressors:
- Internalized stigma.
- Fear of rejection.
- Concealment of identity.
- Hypervigilance (e.g., hesitating to disclose one’s partner or history).
- Chronic exposure: Over time, even subtle or indirect stigma accumulates, leading to increased risk of:
- Depression.
- Anxiety.
- PTSD.
- Substance use.
- Suicidal ideation and behavior.
- Avoidance of healthcare, even when urgently needed.
Intersectionality, coined by Kimberlé Crenshaw, this framework examines how multiple identities (race, gender, sexual orientation, class, ability, etc.) interact to create unique experiences of oppression or privilege.
- Clinical and Public Health Implications
LGBT+ people of color may face compounding stigma: Racism within LGBTQ+ spaces and homophobia or transphobia within racial/ethnic communities and healthcare. - Transgender individuals, particularly Black and Latinx trans women, face disproportionate risks for:
- Violence (including state-sanctioned violence).
- Housing insecurity and unemployment.
- HIV infection.
- Lack of culturally competent care.
- KFF data disaggregated by race shows that LGBT+ people of color face even higher rates of poor health, cost barriers, and unmet mental health needs.
Section 1557 explicitly recognizes intersectional discrimination, protecting individuals on overlapping grounds like race + gender identity.
The Fund emphasizes that gender-sensitive care must include lesbian, gay, bisexual, transgender, intersex, asexual (LGBTQIA) health—requiring systems and providers to address diverse sexual and gender identities alongside racial, socioeconomic, and ability differences.
Policy frameworks like Section 1557, though important, fail without clinic- and community-level strategies that account for multi-layered identities.
Lack of inclusive electronic health record fields, policy gaps, and anti-LGBT legislation effects.
Actionable public health interventions:
- EHR fields for SOGI (sexual orientation and gender identity).
- Insurance policy reform (gender-affirming care coverage).
- Workforce diversity and provider training.
- School- and community-based outreach to LGBT+ youth.
- Legislation advocacy (e.g., protecting gender-affirming care).
- Promotion of inclusive language
- “Partner” vs. “husband/wife.”
- Gender-neutral anatomy references (“chest exam”).
- Avoiding making assumptions about someone’s gender identity or sexual behavior.
- Emphasize active listening and patient-driven communication—asking about identity, past negative experiences, and social context without assumptions.
- Intersectional thinking changes clinical questioning: (e.g., “Are you concerned about how your race or gender identity might influence your healthcare experience today?”)
KFF issue brief LGBT+ People’s Health Status and Access to Care (2023).
AMA best practices for LGBT-inclusive care
AMA: Creating an LGBTQ-friendly practice.
APA: Minority Stress and Mental Health