Building a Fairer System: How Policy and Community Action Address the Root Causes of Health Inequity

The fight for health equity is one of the most important missions of our time. It means working to make sure everyone has a fair and just opportunity to attain their highest level of health. When we talk about health in America, we often focus on hospitals, doctors, and prescription medicines. We think about what happens after someone gets sick.

But we know that medical care is only a small piece of the total picture. If we really want to fix long-standing disparities, we have to look outside the clinic and into our neighborhoods, schools, and workplaces. We need to examine the systems that decide whether people have the tools they need to stay healthy in the first place. That is the foundational purpose driving the work of the Centers for Medicare & Medicaid Services (CMS) and its many partners across the country.

Why We Must Look Beyond the Clinic Walls

We cannot achieve equitable health outcomes by only focusing on individual behaviors or choices. A person’s health is deeply tied to where they live, how much money they make, and the quality of their educational opportunities. These non-medical factors are formally called the Social Determinants of Health (SDOH), and they are responsible for the vast majority of health discrepancies we see today.

If someone lives in a neighborhood without clean air or safe parks, or if they cannot afford nutritious food, a doctor’s visit alone will not solve their problems. That’s why our approach must be multi-faceted. We have to change the conditions that make people sick, not just treat the sickness once it arrives. This requires cooperation among federal agencies, state governments, local non-profits, and private industry.

Defining the Real Barriers to Health

We often think of health issues as personal struggles. Maybe someone has trouble managing a chronic disease like diabetes or hypertension. We might focus on prescribing medication and counseling them on diet.

However, the real difficulty is almost always rooted in social or economic struggle. If that person works two minimum-wage jobs and relies on unreliable public transit, finding time for exercise or affording expensive fresh produce becomes impossible. The system itself has put up barriers.

The Impact of Economic Stability

Money is one of the biggest drivers of health and disease in America. People with low incomes face compounding risks that affect their bodies and minds. Financial pressure creates chronic stress, which contributes to poor physical health over time.

It is tough to think about preventive care when you are worried about keeping the lights on. Many families are forced to choose between paying rent, buying food, or purchasing necessary medications. Policies that promote economic security, like access to good jobs and fair wages, are therefore essential public health strategies.

Housing and Neighborhood Factors

Where a person lives determines their access to resources. This includes everything from clean drinking water to high-speed internet. These neighborhood factors are often overlooked when discussing health care policy.

But safe, affordable housing is health care. When a home has mold, pests, or lead paint, it directly causes respiratory and developmental issues, especially in children. When a neighborhood lacks reliable transport, accessing medical appointments or healthy food stores becomes a major ordeal.

The Role of Systemic Inequities

Health inequity is not accidental. It results from centuries of policy decisions and institutional practices that favored certain groups over others. We have a moral imperative to face this history directly.

Ignoring the systemic nature of these problems means we will only ever achieve small, temporary fixes. True equity requires deep, structural change across multiple sectors, including justice, finance, and education. We have to commit to dismantling the structures that perpetuate disadvantage.

Addressing Historical Disadvantage

Institutional racism and bias built into our systems still shape the opportunities people have today. Redlining, for example, determined where federal loans went, locking many minority communities out of wealth building and quality services for generations.

These historical practices continue to affect the physical environment of communities, leading to worse air quality, under-resourced schools, and a lack of primary care doctors. CMS and other federal health bodies must prioritize initiatives that specifically address the consequences of this long-term disinvestment.

Making Policy Choices Visible

Every major public policy, whether about transportation funding or school lunch programs, has a health consequence. Our job is to make those consequences clear to decision-makers. We must ask: Who benefits and who is burdened by this proposed action?

When we analyze policies through an equity lens, we move away from making assumptions about individual failure. We see instead the clear systems that may block a path forward. For instance, sometimes people just want a simple, clear mechanism for wellness, something like clear glass pipes to run water through, but the policies surrounding access to necessary equipment are murky and difficult to navigate. If we can make policy choices transparent, we can make health outcomes more fair.

The CMS Framework: A Blueprint for Action

The Centers for Medicare & Medicaid Services developed a comprehensive framework to guide our national work. This plan recognizes that achieving equity requires deliberate, sustained action across five main priority areas. We are working to embed equity into every program and every decision.

We are actively working to move beyond simply acknowledging disparities toward actively fixing them. This means changing the way we collect data, how we evaluate our own programs, and how we interact with the millions of people who rely on us for care and coverage. This effort is large, complex, and absolutely necessary.

Focusing on Data Collection

Data is the flashlight we use to shine a light on unfairness. If we do not collect high-quality, standardized data about the people we serve, we cannot possibly measure where disparities exist or whether our efforts to fix them are working. Poor data equals blind policy.

We must collect demographic information, like race, ethnicity, language, disability status, and geographic location. This information is vital for painting a true picture of health in this country. It allows us to segment results and understand exactly which communities are being left behind.

Standardizing Information Gathering

Collecting information consistently is harder than it sounds. Different hospitals or state programs might ask questions in different ways, or they might not ask key questions at all. This lack of standardization makes it impossible to compare data across regions or programs.

CMS is spearheading efforts to standardize data collection across all CMS programs and partners. This includes using best practices for capturing information on social determinants of health. By standardizing our approach, we build a foundation of truth that helps us craft better, more targeted policy solutions.

Partnering with Local Communities

We cannot solve community problems from an office in Washington D.C. Change happens locally, driven by people who are already working on the ground. Effective policy requires genuine partnership with community-based organizations.

CMS programs must support and empower organizations that are already connected to people who face the most significant barriers. This means shifting funding and resources to those who can meet people where they are, offering direct, tailored support rather than just general healthcare guidance.

Listening to the Lived Experience

The best data comes from listening to the voices of those affected. Patients, caregivers, and community leaders have knowledge about their daily struggles that no spreadsheet can capture. Their “lived experience” is critical intelligence for policy design.

When we create new policies or programs, we must involve community members in the design phase. We must ask them what they need and what truly helps, instead of telling them what we think they should have. This process builds trust and ensures that the solutions we implement are practical and sustainable in the real world.

Changing the Conversation Around Access

Access is not just about having insurance; it is about the ability to utilize the care and resources that exist. Millions of people have health insurance cards but still struggle to get the care they need because of practical issues, such as language barriers or lack of transportation. Our goals, as outlined in the national Healthy People 2030 objectives, demand we address these gaps.

We have to recognize that healthcare access is interwoven with dignity and respect. If a patient feels confused, unheard, or disrespected during a medical encounter, they are unlikely to follow up on treatment or attend future appointments. Improving access means improving the entire experience of care.

Language and Health Literacy

We often use complex medical jargon or print materials only in English, immediately creating a barrier for many populations. If a person cannot read the instructions for their medication or understand their diagnosis, their health outcome will suffer. This is an avoidable inequity.

Federal programs must ensure that all communications are provided in a person’s preferred language and at a reading level they can easily grasp. This is more than just translation; it is about creating materials that promote true health literacy across diverse populations.

Breaking Down Communication Gaps

Imagine being told critical information about a life-altering illness in a language you only halfway understand. That is the reality for millions of Americans with limited English proficiency. Providing professional interpretation services is not a luxury; it is a fundamental requirement of equitable care.

CMS encourages all providers and organizations receiving federal funding to invest seriously in robust language access services. Clear communication is the first line of defense against misunderstanding, medication errors, and mistrust in the healthcare system. We must make the investment needed to bridge these gaps.

Transportation and Care Accessibility

Even with the best medical care available in a city, it means nothing if a person cannot physically get to the facility. Transportation barriers are a huge challenge in both rural areas, where distances are long, and in urban settings, where reliable public transit might not connect to hospitals.

We are working to integrate transportation solutions directly into health care delivery. This includes using data to identify patients who are missing appointments due to transit issues and connecting them with services like medical non-emergency transportation. We must remove every physical obstacle between a patient and their necessary care.

Overcoming Geographic Hurdles

In rural and geographically isolated communities, the challenge is often that providers simply do not exist nearby. This forces people to travel hours for specialty care, adding financial and time burdens that make treatment impractical.

Telehealth offers a promising way to overcome some of these distance challenges. By expanding access to virtual appointments, especially those covered by Medicare and Medicaid, we can bring specialized care directly into people’s homes or local community centers. Policy changes are needed to make sure this virtual access remains permanent and equitable for all.

Supporting the Healthcare Workforce

The people who deliver care—the doctors, nurses, social workers, and community health workers—are on the front lines of the equity fight. But they need the right tools, training, and systems to do their jobs effectively. We must support them if we expect them to handle the complexities of SDOH.

This support goes beyond just giving them higher salaries. It involves redesigning training programs and changing the payment systems so that healthcare providers are rewarded for addressing the root causes of disease, not just for performing procedures.

Training for Cultural Competence

Cultural competence is the ability of providers to acknowledge and work effectively within the cultural beliefs, values, and language of diverse patients. It is essential for building the trust that leads to better health outcomes. Without trust, communication fails, and adherence to treatment drops.

We need to build education on health equity and implicit bias into every level of medical and public health training. This is not a one-time workshop but an ongoing commitment to self-reflection and systemic change within institutions. This sustained commitment helps every provider recognize and address their own unconscious biases.

Shifting Perspectives in Practice

When doctors and nurses learn to see a patient not just as a set of symptoms but as a person embedded in a unique social context, the quality of care improves dramatically. They begin asking about food security or housing stability, making SDOH screening a routine part of the clinical visit.

CMS is working to fund initiatives that train existing health professionals in these equity-focused practices. This shift in perspective transforms the relationship between the provider and the patient from a transaction into a true partnership aimed at holistic wellness.

Incentivizing Equity-Focused Care

If we want the healthcare system to prioritize equity, we must structure the money to match that goal. Traditional fee-for-service models reward high volume—seeing as many patients as possible—which often leaves little time for addressing complex social needs. This model inadvertently drives inequity.

We need to create payment models that reward better outcomes and equity improvements, not just services provided. This means incentivizing collaborative care where medical, behavioral health, and social services work together as a single team focused on the whole person.

Value-Based Care Models

Value-based care is a concept that shifts the focus from the quantity of services to the quality and efficiency of care. Under these models, providers are given financial incentives for achieving specific benchmarks, such as closing disparities in blood pressure control between different racial groups.

CMS is actively implementing and testing value-based models that specifically include equity metrics. By making health equity a factor in reimbursement, we send a clear message: reducing disparities is a core mission of the modern healthcare system, and we will pay for it accordingly.

How Communities Drive Progress

While CMS and other federal agencies set policy, the actual work of advancing health equity happens on Main Street, in local clinics, and at neighborhood resource centers. It is the community, fueled by grassroots effort and local knowledge, that closes the gap between policy and reality.

These local efforts are dynamic and varied, addressing the most immediate and painful needs of residents. When a national policy provides the funding and the framework, community partners provide the innovation and the execution that makes the difference in daily life.

Local Partnerships and Innovation

We see incredible ingenuity at the local level. Community organizations are often the first to identify new needs and develop culturally sensitive ways to meet them. They are building partnerships with food banks, schools, and local businesses to create seamless support networks.

These innovative partnerships demonstrate what happens when different sectors truly align their goals. A partnership between a hospital and a housing authority, for example, can guarantee safe discharge for vulnerable patients, dramatically improving their recovery and reducing readmission rates.

Food Security Programs

Food insecurity—not having reliable access to affordable, nutritious food—is a significant driver of chronic disease. Community programs are working to fight this by providing food prescription programs where doctors can literally prescribe healthy food to patients who need it.

These programs often utilize local farmers’ markets or food banks, linking health care directly to local economic activity. This integration of clinical care and community services is a powerful way to address a core social determinant of health and promote wellness from the ground up.

Advocacy and Accountability

Achieving health equity requires constant vigilance. Community advocates play a vital role in holding large institutions and government agencies accountable for their commitments. They ensure that policy goals translate into real-world change for underserved populations.

This advocacy involves collecting stories, organizing community feedback, and demanding transparency in how resources are allocated. Their relentless focus on equity ensures that progress does not stall and that the needs of the most marginalized are always at the forefront of the discussion.

Holding Systems Responsible

Accountability means transparency in data and clear consequences for failure to address disparities. If a health system is paid to improve quality but the gaps in care between groups widen, there should be mechanisms to address that failure.

Community advocates are essential in pushing for these strong accountability measures. They require us, the policymakers and administrators, to continuously track our own performance and adjust our strategies until true equity is achieved.

Sustaining Momentum for the Future

The effort to achieve health equity is not a one-year project or a single conference theme. It is a generational commitment that requires sustained resources, attention, and political will. We must build durable systems that can withstand changes in leadership and policy focus.

We are focused on planting seeds that will grow into permanent shifts in how American healthcare operates. This means embedding equity not as a separate initiative, but as the foundational principle of all our health policies and funding streams moving forward.

Long-Term Investment

Investing in upstream solutions—like housing, food access, and early education—saves money in the long run by preventing expensive, late-stage illness. However, these investments often take time to show a return, which can make them politically challenging.

We must make the case for sustained, long-term funding for non-traditional health partners. Supporting community capacity building and infrastructure is essential. We need resources dedicated specifically to addressing structural disparities, not just temporary funding boosts.

Funding for Upstream Solutions

One key strategy is braided funding, combining resources from various sources, such as housing grants, agricultural funding, and health care dollars, to tackle complex social issues simultaneously. This coordinated approach maximizes impact and recognizes that a single government agency cannot solve SDOH alone.

CMS and its partners are focused on ensuring that federal dollars encourage this coordination. By rewarding multi-sector collaborations, we incentivize the creation of long-lasting, integrated solutions that address both the clinical and social needs of people.

Measuring True Impact

Measuring the success of health equity work is more complex than counting hospital visits. It requires us to look at population-level metrics, such as life expectancy, access to healthy food, and overall community well-being. These are the true markers of a fair system.

We are working toward a system where every piece of data is stratified by key demographic factors. This way, we can immediately see if a new policy is helping everyone equally, or if it is accidentally leaving certain groups behind.

Defining Success Beyond Numbers

Ultimately, success is defined by stories of real change. It is when a child in a historically underserved neighborhood has the same chance at a healthy life as a child in an affluent suburb. It is when language is never a barrier to receiving life-saving information.

We must keep the human element at the center of our work, constantly asking if our policies are making daily life easier, healthier, and fairer for the people we serve. That commitment to human dignity is the force that will sustain the push for health equity for years to come.

Conclusion

The pursuit of health equity requires a shift in how we think about health itself. It demands we stop seeing health as something solely delivered in a doctor’s office and start seeing it as a reflection of our entire society—our policies, our systems, and our investments in human potential. The work is complex and involves every sector, but the goal is simple: a fair opportunity for health for every person in every community.

We recognize the immense scale of this challenge, but we also feel the deep commitment of thousands of dedicated professionals and community leaders. By centering our efforts on the social determinants of health and operating with transparency and genuine partnership, we can achieve true health equity. We are focused on making the necessary, sustained investments that will ensure a healthier, fairer future for all.