• Center on Health Equity and Access
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Issues and Challenges Associated With Developing Fair, Equitable Health Policy


A well-functioning healthcare system must be coordinated, efficient, cost-effective, and goal-oriented. Unfortunately, these words don’t summarize healthcare services in the United States.

Healthcare access and the ability to obtain needed health services are always paramount. A healthcare system should have mechanisms in place to ensure everyone has continued access to compassionate healthcare that addresses the full range of their needs. A well-functioning healthcare system must be coordinated, efficient, cost-effective, and goal-oriented. Unfortunately, these words don’t summarize healthcare services in the United States.

Despite its substantial efforts and significant progress, the US falls short of providing a high quality and efficient healthcare system. People with insurance have access to the latest medical technology and yet, millions of Americans receive too little medical care.1

Health Insurance

One of the most important obstacles in the United States when it comes to paying for the cost of care is lack of health insurance. Studies indicate that in 2009, more than 50 million individuals in the US had no health insurance. People without any health insurance are more likely to fall into the low-income category. They must pay more for health services and they are more likely to experience a diminished health-related quality of life. In addition, there are many people who have health insurance, but have inadequate coverage and are unable to pay their bills.1 Lack of health insurance adversely affects individuals’ health status, which will ultimately result in reduced utilization of preventive medical services. An uninsured individual is twice as likely as an insured person to go without competent and appropriate medical care.2 More programs need to be developed for public assistance to meet their health needs, break barriers, and help them feel motivated and respected. The primary reasons for not having insurance include income level; employment status; age; education level; race, ethnicity, and immigration status; gender; and geography.3

Income level. Studies suggest that 40% of individuals without health insurance are people with an income below the Federal Poverty Level (FPL) that experience wide disparities. Ninety percent of uninsured individuals get paid less than 400% FPL. These individuals experience lack of access to health services enormously.3

Employment status. Seventy percent of uninsured individuals work for low-wage business, such as factories, mines, construction, forestry, and fishing that do not offer coverage. Families whose primary bread winner is a blue-collar worker are more likely to be uninsured compared with families whose primary earner is a white-collar worker.3

Age. Adults are more susceptible to be uninsured than children because Medicaid and the Children’s Health Insurance Plan offer considerable amount of coverage to low-income children.

Education level. People with a higher degree achieve a higher income and will likely have jobs that provide affordable employment-based insurance. However, more than half of nonelderly adults who are uninsured do not have higher education in the US.3 Literacy education enables such people to become conscious of the structures that oppressed them and then to imagine ways of building the capacity to change those structures.

Race, ethnicity, and immigrant status. The vast majority of minorities in the US are uninsured.3 American Indians and Alaska Natives have lower educational levels, higher unemployment rates, and consequently lower rates of employer-based coverage. Their needs are not acknowledged, and they have not attained full social, political, and economic equality. Native peoples feel unvalued, which initiates poor health that ultimately affects their well-being. They have higher disease rates and lower life expectancy when compared with other racial and ethnic groups in the US. Their population is younger due to higher mortality rate than all other American races. The rates of diabetes, mental disorders, cardiovascular disease, pneumonia, influenza, homicide, and chronic liver disease are exceptionally higher than any other racial or ethnic group. At least one-third of American Indians live in poverty without any health insurance, which plays a significant role in developing a disproportionately high incidence of disease and medical conditions, such as malnutrition, tuberculosis, and high maternal and infant death rates. In addition, poverty and secluded living hinders them to use healthcare facilities.4

One of the most important issues associated with providing healthcare to the Asian population is differences in language and socioeconomic characteristics. It is imperative to increase teaching second language courses, which act as a bridge linking new immigrants to society. Members of the older generation in the Asian population have limited English proficiency and find it very difficult to adjust to a foreign culture and understand healthcare in the US.5 They may prefer traditional forms of medicine and they may not be aware of healthcare programs due to language and literacy challenges. It is essential for organizations to familiarize Asian communities of their eligibility for the healthcare programs. It is necessary to provide one-on-one application assistance, language accessibility, and cultural competency to help individuals in Asian communities.6

Language barriers are also an important hindrance when it comes to providing healthcare to the Hispanic population. In the US, very few healthcare providers speak Spanish. In most circumstances, sick individuals who are unable to speak or understand English rely on friends and family members to translate and interpret. This poses a greater risk as the interpreter may misunderstand or exclude a question that was brought up by healthcare professionals and the patient may omit the embarrassing symptoms.3 This problem will continue to rise until there are more healthcare providers available who are able to speak Spanish. Recruitment of bilingual healthcare professionals is an important element that can enhance quality of healthcare.2 In addition, it is important to have Spanish medical interpreters at healthcare facilities. This will result in better patient-practitioner relationships and communication, which will ultimately increase patients’ likelihood of receiving and accepting appropriate medical care. Studies indicate that when patients interact with clinical members who share a common race, ethnicity, or language, there is a higher chance of rapport building. Conversing in the same language can instill and strengthen the needed cultural values. This will lead to a greater interpersonal care, better medical comprehension, and higher chance of keeping follow-up appointments.4

Gender. Gendered perspectives continue to dominate healthcare and healthcare delivery. Non-elderly men are predominantly uninsured compare to non-elderly women. Among those individuals with insurance, men are more likely to have employer-based coverage. On the other hand, women are more likely to have public coverage because of their lower average income.3

Geography. Unfortunately, geographical variations in the uninsured rate exists in the US. People who live in the rural areas have lower income and higher healthcare needs, but a limited access to healthcare facilities due to shortage of doctors and an uneven distribution of the current workforce.3 A shortage of doctors explains some of the wait times in different states and to rectify the situation, more doctors need to be trained.

Health Care System in Canada

Canada relies on public health insurance system, which is a social program that emphasizes access to healthcare services on the basis of medical needs. Since the healthcare system is mainly funded by public taxations, it basically redistributes the wealth from the rich to the poor, from the well to the sick, and it works very well in equalizing access to healthcare services.3 The Canadian system ensures that all residents have reasonable access to medically necessary services and enhances long-term viability of the healthcare system. It alleviates health adversity for everyone and facilitates the implementation of an excellent service in relation to the complex care issues of the patient population. Canadians have universal access to healthcare services, the latest technology, and highly skilled healthcare professionals. The Canadian healthcare system is based on equity, fairness, and solidarity and provides affordable, accessible, and high quality care. The 5 principles of healthcare in Canada are public administration, comprehensiveness, universality, accessibility, and portability.7

Addressing Social Determinants

There is a need for action against injustices and inequalities in America’s healthcare system. It is essential to address social determinants of health in order to challenge inequality and disparities to ensure better health for all. It is important to create social justice that promotes equity, diversity, and professionalism among all participants in the society. People with different race, gender, age, disability status, socioeconomic status, and geographic location deserve to be treated with dignity and achieve health equity. It is imperative to respect the beliefs and traditions of various ethnical and cultural group regardless of their origin.

Leaders should create an environment in which members of different groups feel safe to express and discuss their identity. They need to learn from successes abroad and focus their policy decisions on what they can do to improve the quality of what we pay for. The US needs to achieve universal coverage for all its citizens.


1. Bodenheimer T, Grumbach K. (2012). Understanding health policy: A clinical approach (6th ed.). New York: McGraw Hill Medical.

2. Sherrill W, Crew L, Mayo R, Mayo W, Rogers B, Haynes D. (2005). Educational and health services innovation to improve care for rural Hispanic communities in the US. Education for Health: Change in Learning & Practice (Taylor & Francis Ltd), 18(3), 356-367.

3. Teitelbaum JB, Wilensky SE. (2013). Essentials of health policy and law (2nd ed.). Boston, Mass: Jones & Bartlett Learning.

4. Spector, RE. (2013). Cultural diversity in health and illness. (8th ed.). Upper Saddle River, NJ: Pearson.

5. Asian American Health Initiative. (2005). Together to build a healthy community. Retrieved from http://www.aahiinfo.org/english/asianAmericans.php

6. Artiga, S. (2013). Health coverage by race and ethnicity: The potential impact of the affordable care act. Retrieved from http://kff.org/disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-the-potential-impact-of-the-affordable-care-act/

7. Romanow, R. J. (2002). Building on values the future of health care in Canada. Retrieved from http://www.collectionscanada.gc.ca/webarchives/20071122004429/http://www.hc-sc.gc.ca/english/pdf/romanow/pdfs/hcc_final_report.pdf

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