Gilbert Berdine MD
Corresponding author: Gilbert Berdine
Contact Information: Gilbert.Berdine@ttuhsc.edu
DOI: 10.12746/swrccc.v11i47.1159
In Health Literacy and Social Determinants of Health,1 the authors make many very good points. There should be no question that Social Determinants of Health are significant contributors to favorable health outcomes. There should also be no question about the importance of Health Literacy as one type of Social Determinants of Health. There are problems, however, in terms of equity vs. equality and who is responsible for achieving equity.
The Figure used by the authors to explain equity vs. equality is a nice example of misunderstanding. There are three pictures of a baseball stadium with a “free” area beyond the fence in the outfield. In each picture, there are three spectators of different heights. In the picture illustrating “equality,” each spectator has been provided with a single box to stand on. The tallest spectator has a great view of the game. The intermediate height spectator has a limited view of the game. The shortest spectator cannot see the game at all. This panel illustrates equality of treatment: each spectator had the same opportunity provided by the community. In the picture illustrating “equity” each spectator receives different aid according to his need. The tallest spectator needs no aid to see the game. The intermediate height spectator needs one box to stand on to see the game. The shortest spectator needs two boxes to see the game. This panel illustrates “equity” as equality of outcome. The right panel illustrates “accommodation” as replacing the wooden (opaque) fence with a chain link (transparent) fence. All of the spectators have equal views without any boxes.
There are several problems with the above illustrations. Why did the fence exist in the first place? The fence existed as an obstruction to “free” view by the public unless they purchased a ticket for a seat in the stadium. It is unclear that there exists any natural right or human right to watch the game for free. Baseball is a business. Revenue from tickets to see the performance is used to pay the players who provide the entertainment. The stadium cost money to build.
To extend the above metaphor to health care, if one expects the health care providers to provide “equity” or “equality” or “accommodation,” the providers will promote services that are in the best interest of the providers rather than in the best interest of the patients. Everyone may be able to enter the Emergency Room, but one is likely to receive “care” that generates government supplied revenue to the facility whether one “needs” it or not. There are economic reasons why more than 30 computed tomography pulmonary angiograms are ordered for every pulmonary embolus discovered. Computed tomography with pulmonary angiography is an example where “equity” leads to a greater physical toxicity of the environment in terms of radiation exposure.
The authors imply that equity means everyone has a right to the health care dictated by their health. To use the analogy of the ballgame illustration, patients with end stage renal disease need more boxes to see the game than healthy patients. Unfortunately, some of the inequities in health are results of individual choices rather than bad luck. An alcoholic has a much higher likelihood of getting cirrhosis of the liver than the general population. The general population may be disinclined to pay for a liver transplant for the alcoholic just because liver transplants are available to some people. As in watching a baseball game, it is unclear that liver transplants are a natural or human right.
The authors use “health insurance” as an example of equity vs. equality. “For example, offering healthcare to everyone based on insurance and income (equity) does not mean that everyone will be able to afford that insurance to cover their healthcare (equality).”1 Equality of opportunity to obtain health insurance does not mean that everyone will choose to purchase health insurance. Some people will decide that basic necessities like food, shelter, and clothing are more important–who can blame them for doing so. One might say they cannot afford health insurance, so the community should assist them such that the community achieves a state where everyone has equal access to the health care system (analogous to being able to view the game for free). Not everyone will agree, however, especially the ones paying for benefits to other people. More important, what the authors are talking about is not really insurance. As mentioned previously in this Journal,2 insurance is pooled risk for rare and catastrophically expensive events rather than a community subsidy for sick people. This distinction is important.
The last problem with the illustration gets back to paying the players. If the purpose of the fence was to encourage people to buy tickets, and the owners are forced to remove the fence, then why would anyone pay to watch the game? Extending the analogy to health care, if one can get public insurance for free that is just as good as private insurance, then why would anyone buy private insurance? Hospitals lose money, on average, for Medicare and Medicaid patients, so they depend on charging excessive rates to privately insured patients. If there are no paying customers for private insurance, and everyone is on Medicare for all, the hospitals will go bankrupt, so there will be no healthcare for anyone at any price. This might be “equitable,” but it would hardly be desirable. Be careful what you wish for.
Article citation: Berdine G. Equity vs. equality. The Southwest Respiratory and Critical Care Chronicles 2023;11(47):73–74
From: Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
Submitted: 3/23/2023
Accepted: 3/25/2023
Conflicts of interest: none
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