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Why equity in women’s health demands an integrated approach

Research supports what most Americans understand intuitively: A person’s health is strongly linked to where they live, learn, work, and play. These variables, often stratified by race, are known as social determinants of health (SDOH), and they include everything from education and employment to food, transportation and safety.1  To see SDOH in action, consider that during the pandemic women with health and economic challenges experienced worsening health conditions that, Kaiser Family Foundation researchers warn, could translate into higher numbers of severe health issues in the near future.2 

From both an ethical and business perspective, the case for change is clear and urgent. And, indeed, many health payers and large employers have made diversity, equity and inclusion (DEI) initiatives a top priority. SDOH, meanwhile, have become an increasingly central part of conversations about lessening disparities and improving access and care.

But when it comes to improving women’s health, the solution won’t happen only through a SDOH stance or only through DEI initiatives. Rather, women’s health equity requires an integrated approach that recognizes making progress in SDOH and DEI are often mutually reinforcing.

A knot of inequity

From Alzheimer’s to osteoporosis, migraines to strokes, women face higher risks than men for many health conditions—sometimes, in part, because of biological factors, but also shaped by social disadvantages, including gender bias in medical research and clinical care, and uneven health literacy (3,4,5,6). Heart disease, for instance, is the No. 1 killer of American women, responsible for 1 in 5 female deaths.7 Yet there’s no physical reason women should die from heart attacks at higher rates than men. In fact, a study in the Journal of American Heart Association found that when women receive the same interventions as men, their survival rate is the same.8 

Those widespread health disparities are often compounded for women of color, with devastating consequences. Black women, for instance, are 1.7 times more likely to be diagnosed with diabetes than their non-Hispanic white counterparts, and 2.3 times more likely to die from the disease — a statistic that far outstrips the disparity that exists along racial lines alone.9

Programs aimed at closing the racial gap in diabetes care management—without also recognizing the SDOH that help drive those gaps—fall far short of achieving true health equity. But so, too, do programs that don’t take into account the unique and powerful role that gender plays in a person’s health and health care.

Conversely, benefits and programs that take aim at women’s health inequities or are focused on the maternal health crisis can’t realize their full potential unless they are designed with diversity and inclusion at their core. 

More expansive, more effective

Both those designing health plan benefits and those offering such benefits to their employees increasingly recognize the need to take a more expansive view of women’s health. Alongside robust fertility and maternal care benefits, for instance, addressing health equity requires lessening the often-overlooked barriers women face to accessing and utilizing care.

Consider a 2021 McKinsey survey of large U.S. employers, which found that women of color and LGBTQ+ women have some of the highest levels of unmet basic needs, such as housing, transportation and economic stability.10  Those with one or more unmet basic needs were also 2.4 times more likely to have not received needed physical health care and to have missed six or more days of work in the past 12 months.11

What does an integrated, more expansive approach to benefits design look like? Take, for instance, the issue of family planning and economic stability. Roughly 10% of American women report that they or their partners received medical help to get pregnant. While more affluent patients can afford to pay out of pocket when such services aren’t covered by insurance, other women never obtain that medical care because the financial burden is simply too great.

Finances may end someone’s pursuit of fertility assistance, but the fallout doesn’t end just because that option is off the table. Women who experience infertility are more likely to experience mental health issues (such as depression, anxiety and stress) and social blowback (including both stigma and higher rates of intimate partner violence). And women without access to fertility benefits may turn to lower-cost procedures that are more likely to result in multiple births—and the pricier prenatal care, delivery and neonatal intensive care utilization such births are often associated with.

A more inclusive, integrated approach to benefits—such as rolling out fertility benefits more broadly—doesn’t only put family planning within reach for more women. It betters the clinical outcomes of such planning, while lowering the costs for patients and employers alike.

Another example of a more inclusive benefits approach: a large tech organization rolled out a customized platform promoting childcare and activity offerings, with reimbursement easily accessible in one place.12  Another employer, with 48,000 workers nationally, stepped up with a new health reimbursement arrangement (HRA) supporting COVID-19-specific claims of up to $500. Anyone on the medical plan—including part-time employees, spouses and dependents—was eligible, and by mid-year more than 900 people had participated in the program.13

Benefits design alone won’t solve the issue of women’s health inequity. Doing so will require sustained effort and leadership across multiple and systemic arenas. But in the face of significant obstacles, individual payers and employers can drive better outcomes for women. The cost of inaction is far greater than the cost of trying new and promising approaches.

1 Centers for Disease Control. Social Determinants of Health: Know What Affects Health. Last reviewed September 18, 2021. 

2 Ibid.

3 Buckley RF, et al. Sex differences in the association of global amyloid and regional tau deposition measured by positron emission tomography in clinical normal older adults. JAMA Neurology. doi: Published online Feb. 4, 2019.

4 U.S. Department of Health and Human Services, Office of Women’s Health. Osteoporosis. Page last updated May 20, 2019.

5 Rohmann JL, Rist PM, Buring JE, et al. Migraine, headache, and mortality in women: a cohort study. J Headache Pain. Published March 17, 2020.

6 Centers for Disease Control and Prevention. Women and Stroke. Last reviewed May 6, 2021. 

7 Centers for Disease Control and Prevention. Women and Heart Disease. Last reviewed January 31, 2021.

8 Alabas OA, Gale CP, Hall M, Rutherford MJ, Szummer K, Lawesson SS, Alfredsson J, Lindahl B, Jernberg T. Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction. Published December 14, 2017. 

9 U.S. Department of Health and Human Services Office of Minority Health. Diabetes and African-Americans. Last updated March 31, 2021.

10 McKinsey & Company. Income alone may be insufficient: How employers can help advance health equity in the workplace. Published December 3, 2021.

11 Ibid.

12 Optum Forum 2021. Enabling Health Equity in the Workplace. 

13 Ibid.

Disclaimer: Stock photo. Posed by model.