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Why America’s health equity investment has yielded a marginal return

Learning from past efforts can help the health community succeed in the future.

Three questions to ask:

  • What financial investments have been made to address health disparities in the last two decades?
  • Why have investments to date failed to achieve success in health equity?
  • What is a framework that can be used going forward for sustained health equity impact and accountability? 

How EY can help

  • EY Center for Health Equity

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Executive summary

 

Accelerated by the COVID-19 pandemic, health equity has emerged as a mainstream national conversation. The impacts of the public health emergency were disproportionately felt across society, raising our collective consciousness to the reality that more needs to be done to achieve health equity. To this end, the Biden administration and the U.S. Department of Health & Human Services (HHS) have prioritized achieving health equity through interventions to eliminate health disparities in vulnerable populations.¹ The Centers for Medicare & Medicaid Services (CMS) has taken steps to align provider reimbursement with the addition of new health equity-related reporting measures to the FY23 Inpatient Prospective Payment System (IPPS).² Further, the National Committee for Quality Assurance (NCQA) has expanded its race and ethnicity stratification reporting requirements for several Healthcare Effectiveness Data and Information Set (HEDIS) quality measures to drive health plan accountability on disparities within their member populations.³

 

The 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care offered recommendations to address health equity, including systemic interventions into health care financing and assets, clinician workforce pipeline diversification, funding of community-based care and organizations and accountability for more robust collection of health disparity data. Most importantly, it recommended investments to alleviate root causes driven by systemic bias in society and within health systems.⁴

EY research and analysis found that at least US$179 billion has been invested by the US government, philanthropic organizations and corporations over the last 20 years to advance health equity.
 
Figure 1: Total investment in health equity

Time frame

Sector

Dollars invested

2002–2022

Government

$173b

2002–2022

Philanthropy

$4b

2012–2022

Corporations

$2b

Total investment in health equity

$179b
Source: EY analysis

To assess the scale of funding in this space, Ernst & Young LLP deployed advanced analytic tools to aggregate investments made toward health equity from 2002 through 2022. Inputs to this analysis included financial reports, regulatory disclosures, organizational annual reports and press releases to identify specific programmatic investments aligned to health equity goals. The assessment is limited by inclusion of only publicly available data vs. all non-disclosed or privately made health equity investments, and the requirement that terms relevant to the elimination of health disparities and advancement of health equity be present in program announcements to trigger inclusion. As such, the assessment likely underestimates the total value of investment in health equity over the time frame studied.

Despite this significant level of investment, only marginal impact has been demonstrated in eliminating health disparities and achieving health equity. As renewed efforts are being developed to advance health equity across federal and state governments, regulatory organizations, public health agencies and health care systems, the question that must be addressed now is: Why have past efforts failed, and what have we learned to help achieve success going forward?

This paper will:

  1. Explore the scope and sources of financial investments made to address health disparities in the two decades since publication of Unequal Treatment
  2. Examine the limited progress made on key health indicators for racial and ethnic minorities
  3. Explain why investments to date have driven population-level improvements while failing to achieve success in health equity
  4. Offer a framework for sustained health equity impact and accountability moving forward

Introduction

The history of health disparities in the US has long been associated with unequal socioeconomic conditions and access to medical care. Research into root causes of health disparities has substantiated the role of systemic racism and structural inequities in US society broadly and within health care and public health systems specifically.

Despite innovation in how health care is accessed, delivered and paid for in the US since the mid-1960s, when the Medicare and Medicaid programs were signed into law — providing access and coverage for 35% of Americans today — these population-level improvements continue to be underpinned by stark health disparities that have persisted or even worsened for Black and Brown Americans and other vulnerable populations.⁵

Investing in efforts intended to advance health equity gained momentum in 1990 when HHS released its Healthy People 2000 strategy with the measurable goal of improving health of all Americans by the end of the century.⁶ Thirty years since this initial effort and now guided by the Healthy People 2030 strategy, it is evident that while the US has made progress in the overall health status of Americans, health equity has not been achieved.⁷,⁸

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Chapter 1

Health equity funding landscape: scope and sources

Government, philanthropy and corporations are the key sectors leading investments.

Health equity funders differ in their motivations for investment, depth of understanding of the drivers of health inequities and sophistication for strategy execution to accelerate improvement. The key sectors leading investments in health equity in the US include government, philanthropy and corporations.

Government

Federal agencies have invested at least $173 billion to advance health equity for marginalized populations from 2002 to 2022 (Figure 2).

Figure 2: Federal governmental investments toward health equity

Time frame

Government agency

Dollars invested

2002–2021

Substance Abuse and Mental Health Services Administration (SAMHSA)

$55m
2005–2020

Centers for Medicaid & Medicare Services (CMS)

$7m

2012–2022

Centers for Disease Control and Prevention (CDC and CDC Foundation)

$5b

2013–2021

Health Resources and Services Administration (HRSA)

$106b
2013–2021

U.S. Department of Health & Human Services (HHS)

$62b

2018–2022

U.S. Food and Drug Administration (FDA)

$8m
Source: EY analysis

The government plays multiple roles in health care and health equity — as the leading payer for low-income and senior populations, public health care providers, national health data collectors, research funders, industry regulators and policymakers. In these roles, federal and state government agencies have made significant contributions toward health equity goals. These investments aim to equip agencies, administrators, health practitioners and community leaders at all levels of care delivery and payment to develop and implement strategies for equitable population health improvement, often in partnership with community-based organizations.

Governmental funding, however, has often not been activated to its full potential by public health, health care and community-based organizations. For example, the federal government allocated an estimated $2.5 billion in 2021 to address COVID-19-related health disparities among underserved populations, yet only a fraction of this money has been spent by recipient agencies a year after funding distributions, suggesting capacity and infrastructure barriers are hindering efficient use of available health equity resources (Figure 3).⁹

Figure 3: Lack of spend tackling COVID-19 health disparities, May 2022

State/Health department

Funding received

% spent of total awarded

California
$33m

11.6%

Illinois

$29m

0.5%

Mississippi

$48m

16.9%

Missouri

$36m

0%

Pennsylvania

$28m

6.3%
Source: EY analysis

Philanthropy

The philanthropic sector is pursuing investments in health equity using approaches that respond to the health and wellbeing needs of underserved and historically marginalized populations. Attention to health equity has grown in philanthropic circles, with leading foundations increasingly prioritizing strategies for grant making, capacity building and ecosystem development activities. According to EY analysis, leading philanthropic organizations pledged at least US$4 billion toward advancing health equity from 2002 through 2021 (Figure 4). However, philanthropic investments and charitable giving may be time-bound and not holistically coordinated or aligned to the business sector. These factors, individually or together, may limit the impact philanthropic investment has had on the underlying causes and economic incentives that perpetuate disparities.

Figure 4: Select philanthropic investments toward health equity

Time frame
Philanthropic organization

Dollars invested

2002—2021

Robert Wood Johnson Foundation

$51m

2004—2021

The California Endowment
$3b
2004—2022

Advancing a Healthier Wisconsin Endowment

$319m

2007—2021

W.K. Kellogg Foundation

$153m
2013—2021

Kresge Foundation

$50m

2015—2021

NY Health Foundation

$193m

2017—2021

Healthy Communities Foundation

$25m

2017—2021

Packard Foundation

$35m
Source: EY analysis

Corporations

According to EY analysis, corporations have invested at least US$2 billion to advance health equity from 2012 through 2022. Considering the economic scale of the corporate sector, the estimated amount publicly pledged toward health equity initiatives is likely less than the total funding toward health equity goals. For example, access to affordable, safe housing is a key social determinant of health, but not all investments in affordable housing development and corporate financing are adequately captured.

As employers and market shapers, all corporations across sectors are invested in workforce health and wellness as a driver of business resiliency and sustainability. Corporate investment in health equity materializes as corporate philanthropic giving or advocacy efforts to improve political and social determinants of health for their employees, consumers and communities. In the case of health care organizations, they materialize as more direct investments in care access enhancement, community engagement improvements and research.

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Chapter 2

Targeted programs, populations and outcomes achieved

Persistent health disparities are disproportionately affecting communities of color.

To date, the field has lacked a unified call to action on health disparities, failing to align around a collective commitment to drive meaningful change. While the recommendations put forth in Unequal Treatment are still relevant today, systemic bias has been largely unaddressed.¹⁰ A 2023 Journal of the American Medical Association (JAMA) review found that of more than 150 health equity and social needs interventions, only 9% incorporated an understanding of the root causes of health inequities into their conceptual design.¹¹ Health systems have made intentional progress in improving health equity performance since 2002, yet impact is constrained by the upstream drivers of health inequity that are generally beyond their direct control. This reality is reflected in the persistent health disparities disproportionately affecting communities of color, including:

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Chapter 3

Why have investments to date failed to achieve health equity?

Five organizational factors limit the impact of health equity investments.

Limitations in understanding impact

To improve the return on health equity-focused investments, the field needs greater understanding of what funding is available, what the priorities and goals of each program are, the impact of interventions on diverse populations, and how to achieve greater alignment across different initiatives. 

Across these areas, the language the field uses to talk about health equity has evolved significantly since the publication of Unequal Treatment. For example, while the social determinants of health are a broadly understood concept today, this language was not yet part of our collective lexicon in 2003. Funders today frame and approach issues in inconsistent ways, making synthesis of trends across investments and priority areas challenging. Nonstandard measurement approaches currently focus on data collection rather than meaningful outcome metrics that capture social value creation, and irregular public reporting of health equity expenditures further complicates this reality, resulting in an opaque understanding of current health equity impact.

Barriers to equitable health improvement

Despite the funding directly targeting health disparities, the statistics above underline that the US has seen limited tangible health, social or economic return on equity-focused investments. The US has demonstrated population-level improvements on some health indicators over the last 20 years, yet too many health metrics point to stagnant or growing disparities between populations.

Unequal Treatment illuminated the root causes of health inequities as myriad complex, structural drivers that perpetuate systemic bias across society and its socioeconomic structures.

Health equity-related investments have failed to demonstrate desired social and financial returns due to an avoidance in addressing the interrelated root causes of persistent inequity — systemic drivers such as racism, classism, sexism, ageism, homophobia, transphobia and ableism that shape social determinants across society.²²

In addition to this foundational misalignment on root cause alleviation, EY analysis identified five organizational factors that limit the impact of health equity investments (Figure 11):

Figure 11: Organizational factors hindering impact of health equity investments

Factors impacting health equity investments

Challenges

Insufficient governance and accountability
  • Lack of adequate level of organizational governance and reporting structures
  • Narrow, business-focused KPIs and accountability metrics that do not effectively capture health equity inputs, outputs and outcomes

Limited workforce capacity and skill sets
  • Historic underinvestment in health care and public health workforce development
  • Not enough people with the right skills in the right roles to make progress toward health equity goals

Unsupportive data and technology infrastructure
  • Historic underinvestment in data modernization in health care and public health sectors
  • Organizations lack critical infrastructure to enable cross-sector partnerships, including robust data architecture, technology platforms and collaboration tools

Focus on short-term pilots and immediate proof of concept results
  • Short-time horizons (e.g., one year) for implementation and evaluation do not allow for demonstrating meaningful change and impact
  • Short-term investments make it difficult to assess efficacy of the investment and to make the case for scaling

Mismatched funding requirements and reporting processes
  • Burdensome funding and evaluation processes can prevent money moving to those doing the work of health equity
  • Existing disparities are perpetuated through inequitable distribution of health equity resources
Source: EY analysis

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Chapter 4

Advancing health equity: where do we go from here?

Health organizations should follow a framework and make health equity a priority.

A framework for sustained impact and accountability

To improve the impact and return on health equity investments, funding entities across government, philanthropic and corporate sectors must:

  • Articulate intentional strategy for health equity advancement, backed by execution capabilities and supporting infrastructure to provide oversight, measurement and transparent reporting that drives sustainable impact
  • Align purpose of the investment with ecosystem priorities to amplify impact across coordinated and mutually reinforcing funding strategies
  • Accelerate realignment toward cross-sector collaboration and multidirectional information sharing to address the full range of individual- and population-level social and clinical needs
  • Evolve funding practices toward longer-term commitments and investments (e.g., three to five years or more) that enable organizations to sustainably build solutions, measure impact and normalize collaborative processes that unlock continual improvement at scale
  • Consider funding power dynamics and adopt funder and recipient co-creation processes so that existing power inequities are not perpetuated

Health equity must be an explicit organizational priority to be eligible to receive investment funding. Recipient organizations implementing health equity improvement initiatives must:

  • Develop intentional health equity strategies underpinned by dedicated staff, earmarked assets and strategic oversight
  • Invest in robust data, integrated technology platforms and analytics capabilities to understand pressing disparities, develop targeted interventions and track progress over time
  • Promote sustainability of health equity investments through expanded impact and accountability measures that drive social and financial value creation and provide transparent reporting to critical stakeholders, including communities impacted

Historically, federal and state policy and legislation have not consistently provided incentives aligned with the goals of health equity. New 2023 regulations from CMS and accrediting organizations, such as The Joint Commission, introduced new financial incentives for health equity improvement activities, yet more regulation will be required to drive systemic change.25,26 Federal, state, and local policy development and implementation efforts must:

  • Evolve to account for the systemic barriers to health, wellbeing and opportunity that disproportionately impact communities of color and other historically marginalized groups
  • Allocate additional funding for capacity building, workforce development and technology transformation in accordance with health equity priorities
  • Realign financial incentives to make coordinated, strategic action on health disparities the default
  • Drive measurement and reporting standardization through establishment of consistent KPIs that enable comparison across programmatic investments
Aakanksha Kaul, Arpit Jain, and Rohan Sharma also contributed to this article.

Summary 

With comparatively little impact to show from the more than US$179 billion investment in health equity since the publication of Unequal Treatment in 2003, we must avoid the complacency trap of perpetuating past and marginally effective strategies for the next 20 years. Executing sustainable health equity strategies requires deeper understanding and acknowledgment of the political and structural drivers of health that perpetuate health inequity and a willingness to squarely address them head on. Activity in and of itself is not a metric for success. Organizations must stop conflating activity with achievement.²⁷

A bold willingness to address these upstream systemic drivers must be an integral part of future investment strategies. Going forward, funders must build on lessons learned from past failures. They should be prepared to hold themselves, their programs, their processes, and their people responsible and accountable for meaningful improvement. Achieving measurable health equity impact delivery that drives macroeconomic returns from judiciously deployed investments should be the goal.

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