Promoting Health Equity in the U.S. Workforce – A Moral and Economic Imperative

Abstract

Introduction

In the United States, longstanding health disparities exist¹ which are a result of structural inequities across all aspects of a person’s lifespan, and all settings, including the workplace.² Health equity is a state in which everyone deserves an optimal and just opportunity to be healthy, giving special attention to those at the greatest risk of poor health.³ The year 2020 catalyzed a national conversation on health equity driven by the COVID-19 pandemic. Stark disparities in COVID-19 infection, hospitalization, and mortality rates further highlighted structural inequities in American health and society.^4-6 For example, disparities in cardiovascular disease (CVD) are particularly prominent. The prevalence of total CVD amongst non-Hispanic Black women (59%) is more than 14% higher than the total CVD prevalence amongst non-Hispanic white women (44.6%).⁷ Similarly, non-Hispanic Black men (58.9%) have a roughly 8% higher prevalence of total CVD as compared to non-Hispanic white men (51.2%).⁷

According to one recent analysis, health inequities in the U.S. account for roughly US$320 billion in excess health care spending each year. A separate analysis suggests that such disparities cost the U.S. economy US$42 billion in lost productivity each year.^8,9 Health inequities are also costly for employers. Interestingly, significant health disparities exist even among Americans covered by an employer sponsored insurance plan.¹⁰ Factors like systemic biases and discrimination in the workplace can be barriers to health equity, and workplace bias and discrimination negatively impact employee health, productivity, morale, and retention. Workplaces that mitigate bias and discrimination can experience higher morale, productivity, loyalty, and lower turnover, all of which save employers money.¹¹ However, while an increasing number of employers are offering wellness benefits following the COVID-19 pandemic https://www.shrm.org/topics-tools/research/2020-employee-benefits, evidence increasingly indicates that employee wellness programs often do not benefit all employees equitably, especially low-income employees.¹² which has led to calls for employers and the wellness or well-being industry to critically evaluate their benefits, policies, and programs through an equity lens.¹²

Achieving health equity at work involves creating systems that give all employees fair and unbiased opportunities and resources that allow them to achieve their highest level of health and well-being. However, one study showed that nearly 60% of human resources (HR) professionals report not understanding the term “health equity.”¹³ This indicates that a lack of awareness of key terminology—which is not to say a lack of understanding or activation of the underlying concepts that create progress towards health equity—is one obstacle to effectively promoting workplace health equity. Other barriers include lack of prioritization, limited funding, low staff capacity to oversee implementation, privacy concerns about employee health data, and unhealthy work policies.

Given the documented human and financial costs and lost opportunities associated with health inequities and the role that work plays in individual’s lives, promoting health equity in the workforce is both a social and economic imperative. The remainder of this article describes Health Equity in the Workforce, a national initiative, led by the American Heart Association in collaboration with the Deloitte Health Equity Institute and the SHRM Foundation.¹⁴

Health Equity in the Workforce Initiative

The mission of the American Heart Association (AHA) is to be a relentless force for a world of longer, healthier lives for all. The Association declared its 2024 Health Equity Impact Goal in 2020¹⁵ and 10 associated Commitments to health equity strategically developed based on clear evidence and data as a direct response to the urgent need to address ongoing health inequities.¹⁶

One of these commitments harnessed the resources and influence of AHA’s CEO Roundtable — a leadership collaborative of nearly 50 CEOs committed to improving the health and well-being of their employees and communities.¹⁷ In 2021, under the guidance of member company executives and leading academic figures, the CEO Roundtable published an initial roadmap, conceptual framework, and supporting tools to help employers identify and dismantle practices and policies in the workplace that contribute to structural racism and other health inequities.¹⁸

The new Health Equity in the Workforce initiative is a continuation of the Roundtable’s foundational work that aims to catalyze a national employer movement that centers health equity as a strategic business opportunity and provides employers with current guidance, tools, and resources to advance health equity in their organizations.¹⁴

Goals & Methods

The goal of the Health Equity in the Workforce initiative is to help enable positive health outcomes for 10 million U.S. workers by 2025, which represents approximately 10% of the U.S. workforce earning less than the annual median salary.

Initiative efforts are organized across 5 workstreams:

1. Develop Strategic Relationships: Leverage existing networks and foster new relationships with business and community leaders to expand the reach of initiative solutions, create spaces for peer learning and collaborative solution ideation, and drive impact in areas of greatest need.

2. Empower Employers: Develop and share tools, trainings, and guidance that increases the understanding and adoption of health equity strategies among organizations and the workforce.

3. Embed in Communities: Establish a presence in 8 communities to facilitate the exchange of best practices, connect with trusted local community networks and leaders, and deploy resources in a localized and targeted fashion to drive the greatest possible impact.

4. Measure Impact: Evaluate existing and proposed health equity interventions for effectiveness and provide employers with tools to quantify and report on the impact of their health equity and well-being strategies in support of organizational accountability and transparency.

5. Recognize Achievement: Benchmark organizational health equity advancements and highlight progress to encourage behavioral change across the marketplace.

The initiative is guided by a rigorous evaluation plan and logic model developed in collaboration with a national third-party evaluation organization. The initiative will use a mixed methods approach and the RE-AIM framework¹⁹ to evaluate the initial outputs and short-term outcomes between 2023 and 2025.

While the scope of the initiative is national in focus and is intended to benefit all workers and all businesses regardless of industry sector, priority consideration will be given to “income constrained workers” and industry sectors that employ a large number of such workers. For the purposes of this initiative, “income constrained” is defined based on an annual salary for a single person below the U.S. median, which in 2021 was US$51 826 or US$988 per week.^20,21

The initiative collaborators analyzed the median salary of U.S. workers across twenty industries as defined by the U.S. Labor Bureau and found 12 industries in which annual median salary was less than the U.S. median. These industries—which include accommodation and food services, retail, health care and social assistance, manufacturing, construction and others—represented over 109 million of the roughly 140 million total non-institutionalized, non-farm workers in the U.S workforce in 2021. From this number, the ambitious initiative goal of 10% of this population, or 10 million U.S. workers, was established. The Federal Poverty Level (FPL) was not selected as the metric because the goal of the initiative is not to focus on “poor workers” alone, but rather “income constrained workers” who may not meet the narrow definition of poverty used to evaluate an individual’s eligibility for government assistance programs. To put the rationale in context: in states without Medicaid expansion programs, 1.9 million adults fall into the coverage gap. In states with Medicaid expansion programs,²² Medicaid is only extended to those with income at or below 138% of the FPL (US$20 120 for an individual).²

Collaborators’ Health Equity Efforts

American Heart Association

The American Heart Association’s Office of Health Equity was formalized in September 2018 following an 18-month study of health disparities among diverse populations, especially those from historically marginalized communities. The Office of Health Equity serves to advance internal diversity, equity and inclusion as well as to provide subject matter expertise for externally facing policies, programs, and practices across the organization.

This exploration included a review of the evidence regarding the existence of health inequities, the causes of disparate outcomes, the best practices and solutions available, and the need for organizational action. It was particularly clear that decades of improvements in cardiovascular and stroke outcomes and overall well-being were not being experienced equitably across all populations, with specific disparities by race, ethnicity, gender, sexual orientation, ability, and geographic locations. The Association adopted the following definition of health equity:

Everyone deserves an optimal and just opportunity to be healthy, giving special attention to the needs of those at greatest risk of poor health. No one is disadvantaged from achieving their potential because of social position or any other socially defined circumstance.

American Heart Association cannot achieve its goal of equitable health and well-being for all without addressing the larger issues that create and exacerbate gaps in health outcomes, including the role of the workplace. Consistent with our guiding values, we join other like-minded organizations committed to addressing health equity so that everyone has the opportunity to attain their full health potential.

American Heart Association is committed to:

• Inspiring our staff and volunteers and leveraging our financial assets, our science knowledge and our voice to address issues of equity in our work.

• Sharing ownership of equity across the organization.

• Diversity and inclusion in our work, including our staff, volunteers, researchers, partners and collaborators.

• Using our relationships with others to more effectively align the resources of all organizations to achieving health equity across our ecosystems.

• Aligning and broadening our work in transforming communities, transforming healthcare, changing policy, changing systems and leading breakthroughs in science and technology using an equity first lens and allocating our time and resources accordingly.

• Ensuring that all people are treated with dignity and compassion in all settings.

• Listening to those we serve, amplifying their efforts and taking the appropriate actions to expand opportunities for all to achieve their fullest potential.

• Being accountable for our efforts and transparent in our actions.

American Heart Association has dedicated over US$230 million across 4 years to fund research, investment in community-led solutions, and advocacy efforts, all focused on advancing health equity.

The Deloitte Health Equity Institute

Deloitte’s purpose is to make an impact that matters by creating trust and confidence in a more equitable society. Health equity is a core part of the organization’s equity and social impact initiatives, which include Deloitte’s commitments to help remove systemic challenges to prosperity and create a culture and system that empowers all people to thrive and have fair access to opportunity, as well as the organization’s social impact work to enact positive change and help contribute to solving some of society’s greatest challenges. Deloitte embeds health equity within its internal and external purpose and DEI strategies by focusing on workforce needs, implementing DEI programming, investing in health equity social impact initiatives to reduce systemic challenges to equity, and measuring their progress. Deloitte’s annual US Impact Report shares Deloitte’s broader purpose and DEI strategy, goals, and progress.

The Deloitte Health Equity Institute (DHEI) was launched in 2021 to help address significant health inequities and differences in health that are avoidable, systematic, measurable, and unjust. Deloitte Health Equity Institute focuses on the root causes of health inequities, structural flaws in the health system, and disparities in the social, economic, and environmental drivers of health. Through community investments, research, and collaborations with leaders across public, private, and social sectors, DHEI aspires to be a catalyst for bold action and positive change by advancing health equity as an outcome. In addition, DHEI supports Deloitte’s ecosystem approach on health equity and offers client service teams health equity specialization; galvanizes change by sharing data, research and insights; and supports convenings to promote a multi-sector approach in addressing upstream drivers of health.

Deloitte Health Equity Institute’s Theory of Change strategy guides the integrated approach taken with collaborators to scale evidence-based programs and deploy innovations to further evaluate and address the root causes of health inequity. Deloitte Health Equity Institute employs 3 primary levers—advancing place-based change, supporting innovation, and equipping key decision-makers—to help remove obstacles and advance health equity. Together, these levers support an integrated approach that allows collaborations to scale impact, catalyze additional investment, and advance health equity for more people and communities. Since its inception, DHEI has launched purpose-driven investments to address root causes of health inequities with ∼US$25M invested in ∼50 external organizations with direct impact across 20+ unique geographies.

Society for Human Resources Management (SHRM) Foundation

Advancing health equity in the workplace is a key step in creating a healthier future for all. Disparate health outcomes have been a reality across generations, but the need for health equity has become a priority as public health crises like the COVID-19 pandemic disproportionately impacted under-resourced and systematically marginalized populations. Workplaces are nexus points for addressing and closing gaps around health and well-being. By prioritizing access for employers to tools and resources that address the physical, mental, and social health of all workers, SHRM Foundation will work to improve workplace well-being, increase productivity, and reduce costs—while also improving the happiness and life outcomes of workers.

That’s why addressing health inequities within the workplace is a top priority of SHRM Foundation, the 501(c)3 philanthropic arm of the world’s largest HR professional society, SHRM. Society for Human Resources Management Foundation believes that, within our collaboration with the American Heart Association and the Deloitte Health Equity Institute, we can be a force for social good and provide employer-centric resources to decrease health disparities across the U.S. workforce.

The Foundation mobilizes resources, partnerships, and evidence-based programming to educate and empower HR professionals, hiring managers, and executives as forces for social good. As part of that mission, we work to equip employers with what they need to strengthen workplace health and wellness as a way of tackling a critical societal challenge affecting the world of work and ensuring that more talent and workplaces prosper and thrive. Through knowledge building, the development and deployment of tools and resources, the commissioning of case making research, and the curation of partnerships and communities of practice, we believe we can support employers in creating healthier workplaces and a healthier world.

Workforce Health Equity Actionable Strategies

Employers have a unique opportunity to improve the health and well-being of their employees by taking action to prioritize equity and eliminate systemic bias and discrimination in the workplace. This work requires organized and collaborative efforts to address the social, or non-medical, drivers of health on a broad scale, which starts with the development of an evidence-based framework for advancing workforce health equity.

The Health Equity in the Workforce initiative has developed 19 actionable strategies based on emerging best practices to advance workforce health equity:

1. Prioritize health equity as a strategic business imperative by embedding it into the mindset, strategy, operations, resource allocations, and talent.

2. Implement workplace health and well-being benefits, policies, programs, and systems that have been intentionally designed to help promote optimal and just opportunities for all employees to achieve their optimal health and well-being.

3. Train managers in health equity and equip them with resources to implement and sustain health equity strategies.

4. Take steps to minimize bias and discrimination in hiring and retention practices.

5. Advocate for culturally and linguistically effective training for all employees.

6. Offer paid family, medical, and sick leave.

7. Offer comprehensive and affordable health care coverage for all employees without regard to racial or ethnic backgrounds.

8. Offer diversity, equity and inclusion training for all employees. Note: Given the shifting policy environment at the state level, we recommend that these activities are carefully reviewed in consultation with legal and HR advisors prior to implementation to assess risk as well as compliance with any applicable laws.

9. Support employee financial well-being through financial education, benefits and other resources.

10. Adopt anti-discrimination principles and implement anti-discrimination policies (e.g., race, gender, religion etc.).

11. Promote employee health literacy and employee benefits literacy.

12. Review communications for cultural appropriateness, diverse representation and accessibility.

13. Offer and promote the use of employee assistance programs (EAPs).

14. Include equity metrics and indicators in performance processes and evaluations.

15. Ensure employees have a voice in organizational decision-making, where appropriate.

16. Ensure pay equity and promote a living wage.

17. Look for opportunities to expand diversity of supplier pool and engage businesses owned by underrepresented owners (e.g., women-owned, Black-owned, LGBTQIA-owned businesses).

18. Strive to assemble a leadership team that is composed of people from diverse backgrounds and representatives of the workforce and community.

19. Advocate for science-backed public health policies in communities through collaborations and alliances.

Conclusion

As champions for health equity, the American Heart Association, the Deloitte Health Equity Institute and the SHRM Foundation believe that the workplace is one of many vital pathways that should be optimized to eliminate inequities, mitigate preventable health disparities and advance health equity. Workplace leaders are uniquely poised to identify and remove inequities across all facets of their influence, including operational decision-making, products and services, relationships with employees and external connections with communities and the broader industry ecosystem. We invite these leaders to prioritize promoting health equity as a core business imperative and a guiding organizational value to help ensure the conditions for a healthier, more equitable future for all. Good business and good health go hand in hand.

We are committed to enabling continued progress by developing, piloting and iterating on workplace health equity strategies, and creating space for business and community leaders to collaborate, share experiences, advocate, build accountability and generate evidence in support of this work.

To learn more about the Health Equity in the Workforce initiative and download the Health Equity Employer Resource Guide with actionable strategies for workforce implementation, please visit www.heart.org/workequity.¹⁴

Footnotes

Acknowledgments

The authors would like to thank the following people who contributed to the writing of this article. AHA: Kristi Durazo and Hannah Stebenne. SHRM Foundation: Megan Niewold.

Author Notes

For Deloitte Health Equity Institute: Jay Bhatt, New York - National Office, 30 Rockefeller Plaza, 41st floor New York, NY, United States, 10112-0015, jaybhatt@deloitte.com. For SHRM Foundation: c/o Megan Niewold, SHRM Foundation, 1800 Duke Street, Alexandria, Virginia 22314, megan.niewold@shrm.org

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Ndugga

Artiga

. Disparities in Health and Health Care: 5 Key Questions and Answers; 2023. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/. Accessed November 5, 2023.

Churchwell

Elkind

MSV

Benjamin

, et al. Call to action: structural racism as a fundamental driver of health disparities: a presidential advisory from the American Heart association. Circulation. 2020;142:e454-e468.

American Heart Association . Structural Racism and Health Equity Language Guide; 2023. https://professional.heart.org/-/media/phd-files-2/science-news/s/structural_racism_and_health_equity_language_guide.pdf?la=en. Accessed November 5, 2023.

Centers for Disease Control and Prevention . COVID Data Tracker; 2023. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed November 5, 2023.

Gawthrop

. The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S; 2023. https://www.apmresearchlab.org/covid/deaths-by-race. Accessed November 5, 2023.

Mackey

Ayers

Kondo

, et al. Racial and ethnic disparities in COVID-19–related infections, hospitalizations, and deaths. Ann Intern Med. 2021;174:362-373.

Tsao

Aday

Almarzooq

, et al. Heart disease and stroke statistics—2023 update: a report from the American Heart Association. Circulation. 2023;147:e93-e621.

Bhatt

Gerhardt

Davis

Batra

Dhar

Rush

. US Health Care Can’t Afford Health Inequities. Deloitte; 2022. https://www2.deloitte.com/us/en/insights/industry/health-care/economic-cost-of-health-disparities.html

Turner

. The Business Case for Racial Equity: A Strategy for Growth. W. K. Kellogg Foundation; 2018. https://altarum.org/sites/default/files/uploaded-publication-files/WKKellogg_Business-Case-Racial-Equity_National-Report_2018.pdf

10.

Morgan Health, NORC . Health Disparities in Employer-Sponsored Insurance; 2022. https://www.norc.org/content/dam/norc-org/pdfs/jpmc-morgan-health-norc-report-ada1.pdf

11.

Allen

SHRM Foundation . Retaining Talent: A Guide to Analyzing and Managing Employee Turnover. SHRM Foundation; 2008. https://www.shrm.org/hr-today/trends-and-forecasting/special-reports-and-expert-views/documents/retaining-talent.pdf

12.

Sherman

Weaver

. Quantifying value of worksite well-being programs with a health equity lens: it’s time to raise the bar. Am J Health Promot. 2023;37:760-762.

13.

Jellyvision . It’s Time to Confront the Health Equity Problem. Chapter 1: Less Than Half of HR Pros Understand Health Equity; 2022. https://www.jellyvision.com/survey-report/health-equity-statistics/less-than-half-of-hr-pros-understand-health-equity/

14.

American Heart Association . Driving health equity in the workforce. 2023. https://www.heart.org/en/healthy-living/company-collaboration/well-being-works-better/health-equity-in-the-workforce

15.

American Heart Association . 2024 health equity impact goal. 2023. https://www.heart.org/en/about-us/2024-health-equity-impact-goal. Accessed November 5, 2023.

16.

American Heart Association . 10 Commitments Impact Report | 2021-2022; 2023. https://www.heart.org/-/media/Office-of-Health-Equity-Files/Champions-of-Health-Equity/10_Commitments_Report_for_2021_2022.pdf

17.

American Heart Association . AHA CEO roundtable. https://ceoroundtable.heart.org/. Accessed November 5, 2023.

18.

American Heart Association . Driving Health Equity in the Workplace; 2021. https://ceoroundtable.heart.org/ceorthealthequitymanuscript/

19.

Glasgow

Vogt

Boles

. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-1327.

20.

U.S. Bureau of Labor Statistics . 2021 annual averages ‐ household data ‐ Tables from employment and earnings: Table 37. 2023. https://www.bls.gov/cps/cps_aa2021.htm

21.

U.S. Bureau of Labor Statistics . Occupational employment and wage statistics. 2023. https://www.bls.gov/oes/. Accessed November 5, 2023.

22.

Rudowitz

Drake

Tolbert

Damico

. How many uninsured are in the coverage gap and how many could be eligible if all states adopted the Medicaid expansion? 2023. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/. Accessed November 5, 2023.