Twenty years after the groundbreaking Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the US health system is still fundamentally broken. Racism and its pernicious legacy affect the conditions in which Americans live, the places they live, and the ways that they live. When it comes to health in America, a person’s zip code matters more than their genetic code. A nakedly profit-focused approach to healthcare emphasizes downstream interventions while upstream causes remain largely unchecked. Everyone pays a price, and those who have been made vulnerable by racism pay the most—often with their lives. 

This essay outlines a new vision for a high-performing, universally accessible health system that is organized around health and racial equity. We explore the factors that shape health, examine the relationship between America’s social contract and Americans’ health, and share a vision for a new social contract centered on racial equity and a health system that is consonant with that new social contract.

With examples pulled from diverse US communities and international sources, we highlight the core components of a reenvisioned health system based on that new social contract: 

• a sense of belonging; 
• a people-centered approach that prioritizes relationships; 
• an emphasis on cultural coherence and healing, and on community-level agency; and 
• structures that create springboards to good health, including investments in public health and preventive strategies, community-oriented primary care, and integrated health and social services. 

Why this matters

More than 300 years of racism embedded in American policy has produced enduring health disadvantages. Before ever encountering a health system, the health of many non-white Americans is compromised by discriminatory laws, policies, practices, and narratives. To put it simply, when white America catches a cold, Black and Native Americans get pneumonia.

All Americans pay the cost. The failure to adopt health-protective policies and apply them universally disrupts millions of American lives by predictable, preventable crises. The costs play out every day, leading to a cumulative effect on life expectancy. The health of white Americans is directly damaged from these same causes.

The fractures in the US health system—and in the country’s social contract—can be fixed. The growing diversity of the United States makes this an urgent opportunity.

Key takeaways

• Health is not the same thing as healthcare. Health is the result of a constellation of  factors and conditions that act upon and interact with individuals and environments in ways that affect how a person is able to function. Health is not intrinsically the product of healthcare treatments. 
• Health systems, structures, and policies are part of a broader social contract, and they directly reflect the strength and quality of that contract. Protecting and preserving health in equitable and just ways requires a strong and inclusive social contract.
• A health system should be a public good not a mere commercial undertaking. As such, it requires collective investment and attention, and it carries different expectations for accountability.
• An equitable and just health system must be centered on people—the recipients of care—and relationships, not just on the professionals and institutions that provide care.
• Health inequity is amenable to democratic solutions, particularly where purely technocratic ones have failed. If the US creates a health system that is people-centered rather than profit-centered and that values individual belonging and community-level agency, the country can begin to make discernible progress toward achieving racially equitable health.
• In an equitable health system, local communities must have control over resources, decisionmaking, and policies that shape health opportunities.