Four is greater than three: Health equity added to the Triple Aim of Care

When the Triple Aim of Care (see Exhibit 1) was developed and popularized by Dr. Don Berwick, former administrator of the Centers for Medicare and Medicaid Services (CMS) under President Obama, it was designed to measure the performance of health and care delivery. However, it does not address the equitable inclusion of different segments of our population who participate in the healthcare ecosystem differently. HFS Research believes that equitable inclusion of all populations must be added to the Triple Aim of Care.

The new “Quadruple Aim of Care” (see Exhibit 2) is intended to measure the actual reduction in the cost of care, enhancement in the care experience for all stakeholders, and the improvement in health outcomes.

CMS defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.” Notably, the definition focuses on inclusion, not diversity, so healthy equity includes the most vulnerable, the most fortunate, and those in the middle of our communities.

Exhibit 1: The Triple Aim of Care must be augmented with health equity to address disparities

Source: HFS Research, 2024

The triple aim has been deteriorating and needs intervention

All attributes of the triple aim have been heading in the wrong direction for a long time due to its lack of focus on inclusion. The US spends almost three times per capita compared to the average per capita spent by the Organization for Economic Cooperation and Development (OECD) countries. The growth rate is reaching alarming levels, routinely surpassing nominal inflation rates. Rising healthcare costs hit low-income populations more acutely than the wealthy. This trajectory threatens to pressure governments and individuals to cut back on healthcare services, which would further worsen health outcomes.

Life expectancy in the US has regressed to 1996 levels at a macro level, the worst among developed economies. To further exacerbate the situation, the Centers for Disease Control and Prevention (CDC) indicates that six in 10 people in the US have a chronic condition such as diabetes, hypertension, or obesity.

Lastly, customer experience for Medicare, Medicaid, and CHIP (for eligible children) shows that the ratings have been flat for the last five years, staying about mid-60% for Medicaid and CHIP and in the low 70% range for Medicare, indicating that experiences may have deteriorated.

Health equity is about impacting health outcomes, costs, and experiences consistently across populations

Health equity may sound like an elitist concept, but it is fundamental in assuring everyone has the same opportunity to address their health needs. For a community to be healthy (economically, physically, and mentally), everyone in that community must have the same opportunity regardless of race, gender, education level, economic status, or sexual orientation. The quadruple aim framework (see Exhibit 2) will measure health equity in the context of equal opportunity.

Exhibit 2: Ignoring health equities is a reason for the poor triple aim of care performance

Source: HFS Research, 2024

Health equity must translate into reducing disparities manifested in access to care (uninsured or underinsured), access to nutrition (prevalence of a food desert), access to resources (education, experts), and the safety of communities (gun violence, substance abuse). This will require thoughtful private-public engagement that goes beyond the feel-good narrative.

Understanding health equity is vital to improving health outcomes

Improving health outcomes for only the wealthiest or a particular race harms communities. It pulls down the productivity and economic activity of a region by unnecessarily reducing the full participation of everyone in the community.

Achieving improvement across the quadruple aim requires ongoing societal efforts to address historical and contemporary injustices. We must overcome economic, social, political, and other obstacles to health and healthcare. This effort must lead to the elimination of preventable health disparities, such as access to care reflected in Exhibit 3, which shows minorities across states to be disproportionately uninsured compared to whites. Consequently, health outcomes for minorities will suffer, becoming irreversible over time and profoundly damaging the potential of the nation.

Exhibit 3: Disparities for people of color are higher across access (uninsured), mortality (avoidable death), and quality of care

Source: Commonwealth Fund, HFS Research 2024

The Bottom Line: Without actively addressing health equity, the goals of the Triple Aim of Care will never be fully realized, which will hurt the nation’s health and productivity.

Minorities experience higher rates of disease and death across a variety of disease conditions. While DNA and hereditary attributes matter, disparities can exacerbate them. Addressing those disparities is an economic imperative to ensure that communities and the nation at large can fully leverage the potential of the entire population to be more productive and drive economic prosperity.