Normative Dimensions in the Concept and Measures of Health Disparities

Two recent examples demonstrate how concerns with health disparities are central to health policies. The first is Healthy People 2020's “focus on identifying, measuring, tracking, and reducing health disparities”. Although not an explicit topic area for Healthy People 2020, health disparities serve as one of four foundation health indicators to track success in meeting the overarching goals of Healthy People 2020. The second example comes from the Affordable Care Act (ACA). According to HealthCare.gov, the Website managed by DHHS to provide information about the ACA, one of the goals of the ACA is to reduce the prevalence of health disparities by “improving access to quality care for all Americans.” Both examples assume a well-defined concept of health disparity and the application of a clear metric to particular health outcomes (e.g., mortality) or determinants of health outcomes (e.g., health insurance). If health disparities were exclusively differences in health outcomes within domains such as age and race, the associated metric would be only statistical. However, not all differences in health outcomes are health disparities; the concept of a health disparity is inherently normative. Thus, assumptions about values are part of any health disparity metric – e.g., welfare optimization vs. opportunity optimization, health promotion vs. health protection. In this presentation, we identify and evaluate some of the value assumptions having the greatest plausibility. We discuss issues of distributive justice (e.g., Rawls), egalitarianism, liberty (e.g., Mill) and personal responsibility as they relate to socially prescribed and implemented goals of reducing or eliminating health disparities.