This article is written by Namgay Choden of 3rd Year of Jigme Singye Wangchuck School of Law, an intern under Legal Vidhiya
Abstract
Disparities in healthcare access represents one of the most persistent challenges in public health. It is often defined as inequities in healthcare access, quality, and outcomes, and these disparities are often driven by systemic social, economic, and environmental factors. It is in these where legal frameworks and policies come into play as they are critical tools in reducing these inequities, with notable examples including the Affordable Care Act (ACA) in the United States and the National Health Policy in India. This article examines the role of law in addressing healthcare disparities through an analysis of these frameworks. It explores the legal approaches to tackling social determinants of health, implementing public health laws, and ensuring data-driven accountability. Challenges and recommendations for future reforms are also discussed to underline the need for equitable and effective healthcare systems.
Keywords
Healthcare disparities, public health law, healthcare access.
Introduction
Healthcare disparities reflect the unequal access to medical services and health outcomes among different population groups. These inequities are rooted in systematic issues such as poverty, lack of education, environmental degradation, and discrimination. They manifest through unequal rates of chronic diseases, preventable illnesses, and mortality, disproportionately affecting marginalized communities.[1]
Laws and policies are seen as powerful tools in mitigating these disparities. By creating frameworks that ensure equitable access to healthcare and address the underlying social determinants of health, legal interventions have the potential to transform public health outcomes. Examples such as the Affordable Care Act (ACA) in the United States and India’s National Health Policy illustrate how laws can drive meaningful change. However, the effectiveness of these measures depends on robust implementation, adequate funding, and sustained political will.
Different Legal Frameworks in Healthcare Equity
The United States: The Affordable Care Act
The Affordable care Act was enacted in 2010 and was seen as a landmark step in addressing healthcare inequalities in the United States. It expanded Medicaid coverage to low-income individuals, provided subsidies to make health insurance more affordable, and introduced protections against discrimination based on pre-existing conditions.[2] These provisions significantly improved access to healthcare, particularly for racial and ethnic minorities who were previously uninsured at disproportionately high rates.
Moreover, the Affordable care Act emphasized on preventive care by mandating coverage for screenings and immunizations. This approach reduced the long-term healthcare costs associated with managing chronic illnesses. By investing in preventive measures, the Affordable Care Act sought to address health disparities before they escalated into costly medical emergencies. However, challenges persist. Despite Medicaid expansion, many states opted not to participate, leaving millions without coverage. Additionally, affordability issues, even with subsidies, continue to deter some individuals from seeking care.[3]
The National Health Policy of India
India’s National Health Policy was first introduced in 1983 and marked a significant step toward addressing healthcare disparities in a rapidly growing and diverse population. The policy focused on establishing a robust primary healthcare infrastructure to provide universal access, particularly in rural and underserved areas.[4] Subsequent iterations of the policy have included measures to integrate healthcare with sanitation, nutrition, and education initiatives. For instance, the policy emphasizes maternal and child health, aiming to reduce infant and maternal mortality rates. Additionally, programs targeting immunization and communicable disease prevention reflect a commitment to addressing public health priorities.[5] Despite these efforts, systemic challenges remain. India’s healthcare system suffers from underfunding, a shortage of medical professionals, and significant urban-rural disparities. Private healthcare dominates in urban areas, often leaving rural populations reliant on under-resourced public health facilities.
What are the Social Determinants of Health?
Social determinants of health are the conditions in which people are born, grow, live, work, and age. These determinants, such as housing, education, income, and social support, play a critical role in shaping health outcomes. Legal frameworks that address these determinants can significantly reduce health disparities.[6]
Healthy People 2030: The United States Perspective
The Healthy People initiative, a flagship public health agenda in the United States, has evolved to prioritize social determinants of health. Healthy People 2030 explicitly links health equity to improvements in education, housing, and economic stability.[7] For example, housing laws that ensure safe living conditions and anti-discrimination employment statutes help mitigate systemic barriers to health.[8] Additionally, programs such as the Supplemental Nutrition Assistance Program (SNAP) address food insecurity, a key determinant of health.[9] These initiatives demonstrate the importance of cross-sectoral collaboration in achieving health equity.
The Indian Context
In India, addressing social determinants such as poverty, unemployment, and environmental degradation is essential for improving health outcomes. Laws targeting labor rights, land reforms, and access to clean water have had mixed success in reducing health disparities. For instance, the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) has provided a safety net for rural populations, indirectly improving health outcomes by increasing household income and food security. However, the neglect of rural healthcare infrastructure and environmental challenges like air and water pollution remain significant barriers. Strengthening legal frameworks to address these determinants is critical to achieving sustainable health equity.[10]
The Global Perspective
Healthcare disparities are not confined to any single country; they are a global challenge requiring coordinated legal and policy interventions. Examining international frameworks and initiatives can provide valuable lessons for nations grappling with inequities in healthcare access.[11]
The World Health Organization (WHO) has consistently emphasized Universal Health Coverage (UHC) as a fundamental goal for achieving global health equity. UHC ensures that all individuals have access to essential healthcare services without experiencing financial hardship. Legal frameworks supporting UHC are pivotal in reducing disparities, especially in low- and middle-income countries where access to healthcare is often limited by financial barriers. Countries such as Thailand and Rwanda have made significant progress in implementing UHC. Thailand’s Universal Coverage Scheme, launched in 2002, provides nearly all citizens with access to a comprehensive package of healthcare services.[12]
Legal mandates require healthcare providers to deliver services equitably, ensuring that underserved populations are not excluded. As a result, the country has seen dramatic reductions in out-of-pocket healthcare expenses and improved health outcomes, particularly among low-income groups. Similarly, Rwanda has adopted a community-based health insurance model, known as Mutuelles de Santé, which covers over 90% of the population. This program is supported by legal frameworks that prioritize equitable healthcare financing and service delivery. Rwanda’s success demonstrates the power of integrating local governance, community engagement, and legal mandates to achieve health equity.[13]
International human rights treaties, such as the International Covenant on Economic, Social, and Cultural Rights (ICESCR), recognize the right to health as a fundamental human right. Article 12 of the ICESCR obligates states to take steps toward the full realization of this right, including measures to prevent and treat diseases, ensure access to medical services, and address social determinants of health.[14]
South Africa provides a compelling example of how constitutional law can enshrine the right to health. Section 27 of the South African Constitution explicitly guarantees the right to healthcare services, including reproductive healthcare. The government is obligated to take reasonable measures to achieve the progressive realization of this right. Legal cases, such as Minister of Health v. Treatment Action Campaign, have reinforced the judiciary’s role in holding governments accountable for health equity. This landmark case required the South African government to provide antiretroviral treatment to prevent mother-to-child transmission of HIV, setting a global precedent for using the law to address healthcare disparities.[15]
Despite these successes, many countries face significant challenges in implementing international health equity frameworks. Funding gaps, political instability, and weak governance structures often undermine efforts to provide equitable healthcare. For instance, countries reliant on donor funding for health programs may struggle to sustain initiatives once external support diminishes. Additionally, disparities within countries, such as those between urban and rural populations, highlight the need for localized legal solutions. International frameworks must be adapted to fit local contexts, ensuring that policies address the unique needs of marginalized groups.[16]
The Role of Public Health Laws
Public health laws are foundational in establishing equitable healthcare systems. They provide the legal basis for initiatives such as immunization programs, disease prevention campaigns, and healthcare workforce training.
The United States Experience
In the U.S., public health laws under the ACA have emphasized the importance of community-based care. Community Health Centers (CHCs), funded by the ACA, have played a critical role in providing care to underserved populations. These centers offer a wide range of services, including preventive care, chronic disease management, and mental health support.[17] Additionally, laws mandating data collection on healthcare disparities have been instrumental in shaping policy. By identifying gaps in care, policymakers can allocate resources more effectively to address these disparities.
The Indian Experience
India’s public health laws, including the Indian Medical Council Act and the Pharmacy Act, aim to standardize healthcare quality and ensure the ethical practice of medicine. The establishment of health programs targeting maternal and child health and communicable diseases further demonstrates the role of law in promoting public health. However, enforcement challenges have limited the impact of these laws. Inconsistencies in funding and governance, coupled with the dominance of private healthcare providers, have hindered equitable access to care.[18]
Data collection
Data collection is a cornerstone of effective public health policy. Without accurate and comprehensive data, identifying and addressing disparities becomes challenging.
The ACA has mandated uniform data collection across federal health programs. This requirement has improved the ability to track disparities and assess the effectiveness of interventions. For example, data on healthcare utilization rates among racial and ethnic minorities has informed targeted outreach efforts and resource allocation.[19]
However, on the other hand, India faces significant challenges due to fragmented systems and limited resources. Inadequate data hampers the ability to identify regional disparities and implement targeted interventions. Strengthening data infrastructure and promoting transparency in reporting are critical steps for improving healthcare equity.[20]
Challenges and Recommendations
Challenges
Despite significant progress, healthcare disparities remain pervasive. In the U.S., issues such as linguistic barriers, limited Medicaid expansion, and affordability challenges continue to hinder access to care. Additionally, the political polarization surrounding healthcare reform complicates efforts to address these disparities.
In India, the challenges are more structural. Underfunded public health systems, a shortage of medical professionals, and a growing reliance on privatized healthcare exacerbate inequities. Urban-rural divides further limit access to quality care in remote areas.
Recommendations
- Strengthen Legal Enforcement: Both countries must ensure robust enforcement of existing healthcare laws. This includes holding providers accountable for ethical practices and ensuring compliance with regulatory standards.
- Increase Funding for Public Health: Adequate funding is essential for addressing systemic barriers. Investments in public health infrastructure, workforce training, and preventive care can yield long-term benefits.
- Enhance Data Collection: Improving data systems is critical for identifying disparities and measuring progress. Both countries should invest in advanced data analytics to inform policy decisions.
- Promote Cross-Sector Collaboration: Addressing social determinants of health requires collaboration across sectors, including housing, education, and transportation. Policymakers should adopt a “Health in All Policies” approach to ensure integrated solutions.
Conclusion
Laws and policies play an indispensable role in addressing healthcare disparities. By targeting systemic inequities and promoting health equity, legal frameworks can transform public health outcomes. The successes of the ACA in the U.S. and the National Health Policy in India demonstrate the potential of well-designed policies to reduce disparities. However, challenges in implementation, funding, and accountability remain. To achieve sustainable health equity, governments must adopt a holistic approach that combines robust legal frameworks, cross-sectoral collaboration, and community engagement. By learning from existing models and tailoring interventions to local contexts, policymakers can pave the way for a more equitable and inclusive global healthcare system.
References
- Samriddhi Kesharwani and Sumant Gidronia, Framework for Public Health Research and Addressing the Role of Law in Health Disparities, SEEJPH, July 30, 2024.
- National Institutes of Health, The National Academies, How Far Have We Come in Reducing Health Disparities? Progress since 2000: Workshop Summary, Accessed through, National Library of Medicine, National Center for Biotechnology Information.
- Don Wright, The Role of Law and Policy in Achieving Health Equity and Attaining Our Health People Objectives, Office of Disease Prevention and Health Promotion, Law and Health Policy
[1] Communities in Action: Pathways to Health Equity, The Root Causes of Health Inequity, Accessed through National Library of Medicines, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK425845/ (last visited on January 22, 2025).
[2] National Institutes of Health, The National Academies, How Far Have We Come in Reducing Health Disparities? Progress since 2000: Workshop Summary, Accessed through, National Library of Medicine, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK114237/ (last visited on January 22, 2025).
[3] Id.
[4] Samriddhi Kesharwani and Sumant Gidronia, Framework for Public Health Research and Addressing the Role of Law in Health Disparities, SEEJPH, July 30, 2024 (last visited on January 22, 2025).
[5] Id.
[6] Communities in Action: Pathways to Health Equity, The Root Causes of Health Inequity, Accessed through National Library of Medicines, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK425845/ (last visited on January 22, 2025).
[7] Health Equity in Healthy People 2030, OASH, https://odphp.health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030 (last visited on January 23, 2025).
[8] Don Wright, The Role of Law and Policy in Achieving Health Equity and Attaining Our Health People Objectives, Office of Disease Prevention and Health Promotion, Law and Health Policy (last visited on January 23, 2025).
[9] Jerold Mande and Grace Flaherty, Supplemental Nutrition Assistance Program as a health intervention, November 11, 2022, Accessed through PMC PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC9803386/ (last visited on January 23, 2025).
[10] Samriddhi Kesharwani and Sumant Gidronia, Framework for Public Health Research and Addressing the Role of Law in Health Disparities, SEEJPH, July 30, 2024 (last visited on January 23, 2025).
[11] Viroj Tangcharoensathien, et al., Global Health Inequalities: more challenges, some solutions, Accessed through the National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC10835631/ (last visited on January 23, 2025).
[12] Universal Health Coverage (UHC), https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc).
[13] Jalil Koohpayehzadeh, et al., Best Practices in Achieving Universal Health Coverage: A scoping review, Accessed through PMC PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC9391760/ (last visited on January 23, 2025).
[14] Right to Highest attainable standard of health (Art. 12 of the ICESCR), August 11, 2000, https://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1AVC1NkPsgUedPlF1vfPMJ2c7ey6PAz2qaojTzDJmC0y%2B9t%2BsAtGDNzdEqA6SuP2r0w%2F6sVBGTpvTSCbiOr4XVFTqhQY65auTFbQRPWNDxL.
[15] Access to Healthcare, South African Human Rights Commission.
[16] Margaret E Kruk, et al., High Quality health systems in the SDG era: time for a revolution, Accessed through PMC PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC7734391/ (last visited on January 23, 2025).
[17] National Institutes of Health, The National Academies, How Far Have We Come in Reducing Health Disparities? Progress since 2000: Workshop Summary, Accessed through, National Library of Medicine, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK114237/ (last visited on January 23, 2025).
[18] Samriddhi Kesharwani and Sumant Gidronia, Framework for Public Health Research and Addressing the Role of Law in Health Disparities, SEEJPH, July 30, 2024 (last visited on January 24, 2025).
[19] National Institutes of Health, The National Academies, How Far Have We Come in Reducing Health Disparities? Progress since 2000: Workshop Summary, Accessed through, National Library of Medicine, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK114237/ (last visited on January 24, 2025).
[20] Samriddhi Kesharwani and Sumant Gidronia, Framework for Public Health Research and Addressing the Role of Law in Health Disparities, SEEJPH, July 30, 2024 (last visited on January 24, 2025).
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