Where is the US Commission on Health Equity?

In a quiet debate published by The Lancet, American public health researchers dispute “who owns health inequalities” , and what health-care reform legislation will do to reduce them. But are these researchers missing the proverbial forest for the trees?

The conversation begins with a piece by Constance Nathanson (2010) which asserts, among other things, that in the absence of universal health care, public health institutions, not the US government, ‘own’ health inequalities in the US and that “adopting some form of universal health care is the USA’s last best hope for reversing health inequalties”.

Researchers Nancy Kreiger and Anne-Emanuelle Birn, however, point to “government-sponsored insurance programmes that cover a third of Americans (Medicare for older and disabled people; Medicaid for millions living in poverty)” and contend that indeed the “USA does “own” health inequalities, albeit inadequately”. Kreiger and Brin also challenge Nathanson’s second point by asserting that “universal medical care alone cannot resolve health inequalities” and cite the need for “societal efforts [which] tackle directly the conditions in which people live and work: the social determinants of health”.

In a response piece, Nathanson seems confused and is not sure if Kreiger and Brin think she is “too hard on the USA or not hard enough”. Nathanson does accept that indeed, “universal medical care alone will not resolve health inequalities” but states that without a “recognition of health inequalities as a significant public and political problem and a responsibility of government—[Americans] are unlikely to have either universal medical care or significant progress toward “tackling the conditions in which people live and work”.

I don’t blame Kreiger and Brin for their response to Nathanson’s article. When I read the piece, I found deciphering Nathanson’s central message difficult and like Kreiger and Brin, was shocked to read what appeared to be an over-simplified and dismal prediction for action on health inequalities in the US.

However, after reading through the debate, it becomes clear that the entire dispute seems to have resulted from disparate interpretations of ‘ownership’.  Nathanson contends that the US government does not “own” health inequalities because there has not been a formal acknowledgment by the government of their existence.  Krieger and Brin attribute ownership of health inequalities to the US government because of the significant burden that befalls governmental institutions in responding to health inequalities.

So both sides are correct, the US government has done little to formally acknowledge inequalities in health, and in the absence of this acknowledgment, the burden for addressing inequalities falls on last-resort, government-sponsored programs.

But who working in public health in the US doesn’t already know this?

What has this debate done to move forward an agenda which seeks to actively reduce health inequalities in the US? A major question that has been sidelined in this debate is, why hasn’t the American government formally acknowledged pervasive health inequalities?

In England, a government commissioned investigation into health inequities has produced a blueprint for taking action on the social determinants of health.

Where is the US commission on health equity?