The role of health care systems in bolstering the social safety net to address health inequities in the wake of the COVID-19 pandemic

For hundreds of years, US health has been characterized by vast inequities in health achievement across groups. For example, at least since the 1800s, disparities in tuberculosis were known to be associated with overcrowded housing, poor ventilation, and malnutrition. The earliest evaluations of the Framingham Heart Study documented disparities in cardiovascular disease by educational attainment. Today, advantaged groups in the US have a 20-year greater life expectancy than disadvantaged groups, while racial and ethnic minority populations and those with lower income and education (among other types of disadvantage) have a greater burden of disease than more advantaged groups. As the scholarship examining these health outcomes has evolved, it has become clearer that these inequities are caused by foundational social and structural forces, stemming from historical structural conditions that carry to the present day.

Despite this understanding, the US is unique among high-income nations in approaching disease as a problem to be solved almost exclusively by health care systems. This has resulted in an underinvestment in resources to address social and structural determinants such as poverty and housing, such that the US spends more on health care than any high-income country but has the least to show for it in terms of health. Not only does the US have worse outcomes on average than other high-income nations, but also greater inequities between those of higher and lower socioeconomic position.