Measuring Equity in an Age of Disinvestment: A Critical Look at IHI’s New Framework
The Institute for Healthcare Improvement’s (IHI) 2025 white paper, Advancing Health Equity: An Approach to Systematically Identify and Evaluate Health Disparities, offers a structured, evidence-based pathway for health systems to measure inequities in care.
It arrives at a crucial moment.
The very concept of “equity” has become politically fraught, and when public health infrastructure itself faces unprecedented erosion. The document is methodical, but it also reveals a growing tension in American health policy: how can organizations standardize the measurement of fairness in a system that’s politically fragmented, financially strained, and ideologically polarized?
A Step Forward — and a Sign of the Times
At its core, IHI’s white paper outlines a four-step approach to identifying, stratifying, and quantifying disparities within health systems. The model begins by helping organizations define a health equity initiative, determine relevant sociodemographic stratifications (race, ethnicity, age, disability, language), and establish reference points for comparison, culminating in quantifying disparities and their practical, clinical, and community significance.
This is a sound and necessary progression. The field has long lacked a unified methodology for tracking inequities in health outcomes. The report’s insistence on documenting rationale, ensuring data quality, and aligning with both regulatory and community standards is, in many ways, a roadmap for professional rigor.
Yet, the very need for such a framework also highlights how fragmented the health equity landscape has become. Twenty years after the Unequal Treatment report, we still don’t have a national consensus on how to define and measure fairness in health. Instead, we have a patchwork of state mandates, CMS incentive programs, and philanthropic pilots. IHI’s framework may help bring some order to the chaos, but it does not fully engage with the deeper political and institutional rot that allows inequity to persist.
Measurement Is Not Neutral
The white paper positions measurement as the cornerstone of progress: “What gets measured gets improved.” But measurement, in this political moment, is not a neutral act. Every decision about what to stratify, whether it is race, income, geography, or gender identity, reflects underlying values and priorities. Some states are already moving to restrict data collection on race or gender; others are weaponizing “anti-DEI” laws to undermine the very kinds of metrics IHI recommends.
That tension matters. When equity indicators become politicized, health systems face a chilling effect. Data managers hesitate to collect race-based information. Boards question whether “equity” belongs in the mission statement. Federal grants, once designed to close disparities, are now targets of ideological scrutiny. In that sense, IHI’s white paper risks assuming a technocratic neutrality that no longer exists.
To its credit, the paper acknowledges that “uncertainty in health care priorities, strategies, and the broader regulatory environment” will force organizations to adapt their guidance. But that phrasing softens what is, in reality, a political crisis. Public health professionals know firsthand that equity metrics live and die by political will that is in short supply.
The Infrastructure Crisis Beneath the Metrics
The IHI framework presupposes that health systems have the analytic infrastructure, workforce stability, and community relationships necessary to implement its four-step process. But as any county health director or hospital equity officer can attest, many do not.
After COVID-19, the public health workforce has shrunk dramatically.
Epidemiologists have left.
Data analysts have been absorbed into short-term contracts.
Local health departments —the very institutions meant to collect, stratify, and interpret data —are grappling with budget cuts and political interference. Meanwhile, anti-science sentiment has made even basic data collection contentious.
Against that backdrop, a 40-page technical framework risks landing as an academic exercise. It provides a blueprint for measuring disparities but says little about sustaining the measurement machinery itself. Who funds the data systems when federal grants dry up? Who protects analysts from retaliation when their reports reveal racial disparities in maternal mortality? Without parallel investment in governance, staffing, and digital infrastructure, even the best measurement framework may collapse under the weight of neglect.
Power, Not Just Process
One of the most compelling sections of the IHI paper concerns the need to build a “health care environment where everyone thrives.” The authors recognize that organizational hierarchies, cultural forces, and power asymmetries within health care perpetuate inequities. They call for shifting power toward patients and communities and integrating lived experience into decision-making.
That insight is crucial. Too often, equity is treated as a data exercise rather than a power exercise. Counting disparities without redistributing authority risks reinforcing the very structures that produce inequity. Yet, here again, the political headwinds are strong. Across the country, community advisory boards and DEI offices are being defunded or dismantled. Grassroots partners are once again being sidelined in favor of “efficiency” narratives that privilege administrative control over shared governance.
If IHI’s guidance is to have a lasting impact, it must be interpreted not merely as a measurement manual but as a statement of resistance: that even amid political backlash, public health systems have a moral and operational duty to name inequity, quantify it, and act on it.
The Missing Link: Public Health Integration
Another limitation of the paper lies in its narrow institutional lens. The guidance focuses heavily on health systems, hospitals, payors, and entities operating in the clinical sphere. But the frontlines of equity are increasingly outside hospitals: in schools, shelters, public housing authorities, and local health departments, which are struggling to keep food assistance and water safety programs running. By emphasizing organizational metrics, the framework risks further siloing equity work away from population health.
Public health practitioners need bridges between clinical metrics and community outcomes. How do disparities in blood pressure control connect to food insecurity? How does stratifying by race intersect with structural determinants like zoning, labor policy, or Medicaid expansion? The IHI framework provides a way to measure inequities within institutions, but it stops short of linking those findings to the systemic inequities outside them, where the real determinants of health reside.
A Call for Political Courage
Despite these critiques, IHI’s white paper deserves recognition for what it attempts to do: create a standardized, actionable foundation for equity measurement. In a world of shifting mandates and partisan crossfire, such clarity is rare. But the next step requires courage beyond metrics — the courage to name the political forces that obstruct equity, and to defend public health as a public good, not a partisan battleground.
This moment demands more than spreadsheets and stratifications. It requires public health leaders to use those measurements as tools for advocacy, showing lawmakers, funders, and the public that disinvestment in equity and infrastructure is not an accounting issue; it’s a survival issue. Each data gap reflects a gap in trust, a gap in staffing, and ultimately a gap in the health of democracy itself.
Conclusion: Equity as Infrastructure
IHI’s white paper gives us the “how.” What remains uncertain is whether we still have the collective will to act on it. Measurement can illuminate inequity, but only political and moral resolve can close it. As the nation enters another election cycle, where the language of “equity” is weaponized and the scaffolding of public health is strained, the task for practitioners is clear: treat equity not as an add-on to infrastructure, but as infrastructure itself.
Because without it, the entire system — metrics, hospitals, and communities alike — will fail to thrive.
