“Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health,”(1). In an ideal world we wouldn’t need to define this as it would simply be. Sadly, reality necessitates we must be more intentional in considering equity when delivering healthcare in addition to many other areas of life.

The state of health inequity in the US is dire. Communities that are disadvantaged often experience higher rates of preventable diseases, reduced life expectancy, and subsequent increased healthcare costs (2, 3). Diabetes is more common in African Americans, Hispanics or Native Americans, and both mothers and babies are more likely to die if they happen to be Black.  Even equal opportunity offenders like infectious diseases expose our racial disparities, as seen during the recent Covid-19 pandemic, when communities of color experienced disproportionately higher rates of hospitalization and death from the disease.

Recently, the Biden administration launched an equity agenda (4) to “allocate resources to address the historic failure to invest sufficiently, justly, and equally in underserved communities, as well as individuals from those communities.” Two interesting initiatives are worth highlighting: CMS released its plans for the health equity index (HEI) measure, a composite measure leveraging existing STARS measures focused on primary and secondary prevention, and the National Committee for Quality Assurance (NCQA) developed and published its Health Equity Accreditation program (5).

The Health Equity Accreditation program focuses on equipping organizations with the foundations of health equity work. HEI will leverage 2025 and 2026 plan data for a 2027 calculation which will affect future STARS ratings (6). While these are positive steps and the equity framework and STARS measures selected lay out comprehensive processes an organization can put in place and measures of relevance respectively to start to tackle this issue, they are a half step in this author’s opinion.

A mentor of mine when I first moved to the US from the NHS in 2017 gave me a cynical, but accurate assessment of how to elicit change. “If you want something to get changed in the healthcare system, follow the money and redirect it in a way that necessitates it.”

So, right now, how does the money in the US incentivize health inequity to change? The HEI will have financial incentives as it helps boost plans’ STARS ratings, and there will be some redistribution of revenue, but this isn’t the sea change we need to see. The current administration feels this is a priority as evidenced by their position paper (7) and this creates a unique opportunity to capitalize on that momentum and make it essential before the opportunity is lost. Why should there not be extremely aggressive penalties for those who have worse-than-expected outcomes in this space, redistributed to those who do better. Make it financially painful to continue the cycle of small changes and incentivize folks that take big swings to get to the root of the problem.

Ultimately, until we put a real stake in the ground on meaningful, patient-centered outcomes versus half steps and compliance based process measures, and incentivize the players on the field to address the upstream social drivers of these disparities, whether through internal initiatives or comprehensive external solutions, change will be small, costs will continue to rise, and people will die unnecessarily.


  1. Centers for Disease Control and Prevention. (n.d.). Health Equity. https://www.cdc.gov/nchhstp/healthequity/index.html
  2. Thornton, R. L., Glover, C. M., Cené, C. W., Glik, D. C., Henderson, J. A., & Williams, D. R. (2016). Evaluating Strategies for Reducing Health Disparities by Addressing the Social Determinants of Health. Health Affairs (Millwood), 35(8), 1416-1423.
  3. Bush, M. (2018). Addressing the Root Cause: Rising Health Care Costs and Social Determinants of Health. North Carolina Medical Journal, 79(1), 26-29.
  4. Health Affairs. (n.d.). It’s Health Equity Agenda: The Biden Administration Needs Research That Focuses on the Impacted. https://www.healthaffairs.org/content/forefront/its-health-equity-agenda-biden-administration-needs-research-focuses-impacted
  5. National Committee for Quality Assurance. (n.d.). Health Equity Accreditation. https://www.ncqa.org/programs/health-equity-accreditation/
  6. Aspen RxHealth. (n.d.). CMS Health Equity Index. https://aspenrxhealth.com/resource/cms-health-equity-index/
  7. White House. (2022). Maternal Health Blueprint. https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf

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About the author: Claude Pinnock MD MPH - Chief Medical Officer