Several key concepts offer a foundation for understanding health equity and assessing opportunities to improve equity in Medicaid.
Structural racism
Structural racism is defined as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, employment, health care, and criminal justice” (Bailey et al. 2017). Structural racism is expressed as a set of institutional, multifaceted, and systemic laws and policies that has cascading effects across institutions. Race has been a central factor in shaping the policies, discourse, design, and implementation of the Medicaid program and shaping the public perceptions of it (Michener 2022).
Health disparities versus inequities
The Centers for Disease Control and Prevention identify health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations” (CDC 2020). Although the term “health disparities” focuses on differences between groups, a focus on health inequities concentrates on identifying and addressing the root causes of these unjust differences, such as structural racism in the health care system (Everette 2021).
Intersectionality
Intersectionality, a term coined by legal scholar Kimberlé Crenshaw, describes how race, socioeconomic status, age, gender identity, and other individual characteristics intersect and overlap (Crenshaw 1989). Intersectionality provides a framework for considering how Medicaid beneficiaries who have multiple identities experience the health care system differently, including having worse health outcomes, compared with those who do not share similar identities or have not been affected by systems of oppression (e.g., racism, sexism).
Social determinants of health
The social determinants of health (SDOH)—the conditions in the places where people live, learn, work, and play—are among the most influential factors affecting the health of individuals. Examples include a person’s economic stability, access to education, and housing. Medicaid beneficiaries often experience challenges related to SDOH, such as housing instability and food insecurity (MACPAC 2022).