How Much Does the US Public Value Equity in Health? A Systematic Review

  • Sara Khor
    Correspondence: Sara Khor, MASc, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, 1959 NE Pacific St, HSB H-375, Box 357630, Seattle, WA 98195, USA.
    The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
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  • Zizi A. Elsisi
    The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
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  • Josh J. Carlson
    The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
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Published:October 07, 2022DOI:


      • There is a demand to formally incorporate societal preferences for health equity in healthcare decision making in the United States. Nevertheless, it is unclear what health equity means to the US public and to what extent the US public values equity in health.
      • This systematic review summarized and qualitatively assessed studies that evaluated the preference for health equity in the United States and found some evidence that Americans were willing to sacrifice efficiency to achieve more equitable distributions of health in varying degrees.
      • More high-quality studies are needed to generate equity estimates that can be incorporated into traditionally efficiency-driven healthcare decision frameworks.


      This systematic review aims to summarize and qualitatively assess published evaluations on the US public’s preferences for health equity and their willingness to trade-off efficiency for equity.


      Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, we searched MEDLINE and Embase for relevant peer-reviewed publications on this topic before February 2021. We included English-language articles that solicited US preferences regarding efficiency-equity trade-offs and prioritizing healthcare resources based on socioeconomic status, race, disability, or burden of disease. Quantitative and qualitative data captured were decided a priori and iteratively adapted as themes emerged.


      Fourteen studies were found over a 25-year span. Only 4 focused on resource allocation across social groups. Three distinct notions of fairness were studied: equal distribution of resources, priority to the worse-off, and equal health achieved. We found modest support for equal distribution of resources and willingness to sacrifice efficiency for equity in the United States. Prioritizing the underserved was relatively less studied and received less support and was more preferred when resources were scarce, when allocating resources between social groups, or when participants were informed about the fundamental origins of health inequities. Equal health was the least studied, but received nontrivial support.


      The existing literature evaluating the US public’s understanding and preferences toward equity was severely limited by the lack of rigorous quantitative studies and heterogeneous attribute selection and fairness definitions. High-quality studies that clearly define fairness, focus on social groups, and apply rigorous methods to quantify equity preferences are needed to integrate the public’s value on equity into healthcare decisions.


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