Discriminatory barriers that impact access to adequate health insurance, health facilities, and treatments also create scepticism [1]. These challenges are a result of multiple factors, including geographic variability of providers, financial hurdles in health services, cultural differences between the patient and provider and language barriers [2]. Many people in the US are actively blocked from health services and face navigating these challenges alone, which furthers distrust and unwillingness to seek care.

Researchers from the University of Pennsylvania analysed 100,000 patients surveys [3] and found that trust between a provider and patient is linked to improved health outcomes. The study also suggested diversity in the physician workforce plays a role in patients’ experiences, further garnering trust. The US health system has made strides in measuring and sharing patient ratings about their experiences with physicians [4], but more must be done. So the question remains: how do we generate trust within the health system to improve access and utilisation?

In a recent piece published by Economist Impact, “Serving society: how healthcare systems need to democratise their decision making,” the topic of trade-offs is explored as it relates to health system resiliency. Approaches to strengthening health systems that aim to improve efficiency forgo social determinants of health and the concept of fairness in their decision making, creating a seemingly mutually exclusive divide between both. In this divide, equity is associated with fairness and ethical use of health services while efficiency is associated with economical use. However, equity can also mean equal outcomes and equal measures of utility; the utilisation of health services and the patients’ satisfaction in doing so.

Given budgetary limitations, the question of how to do things both fairly and efficiently remains—inevitably resulting in trade-offs. There are people with acute needs and it is imperative to shift the health system to serve the most at risk. The current health landscape disenfranchises vulnerable communities with the system sometimes inaccessible or unaffordable. The need for collectivism in addressing equity in its many forms is necessary as the article series notes “a fair distribution of healthcare does not just mean striking a balance between equity and efficiency, but also balancing among all the different concepts of equity.” [5] An example of equity in this context is moving towards distributing health resources among individuals and/or social groups to expand access.

By only centering efficiency approaches in conversations surrounding health system resiliency, we will not be able to properly address the gaps in access. If ultimately we want to encourage people to utilise healthcare services, there must be an effort to consider how social determinants of health such as socioeconomic status, education access and physical environment factor into trust and access. There is a need to reassess US health priorities: should we focus on expanding overall access or reaching the most vulnerable? How do we expand access to vulnerable communities while also keeping people who do not require resources engaged? Do we preserve and maximise choice to seek health care?Will maximising choice create divisions? These are important questions that need to be considered when realigning health priorities.

Prioritising greater clinical needs cannot happen without paying attention to social determinants of health and how they shape needs and access. Without addressing equity when thinking about the efficiency of health systems, we will continue to reach people without considering specific needs. If we continue down this current path, we will reinforce inequitable health systems that discourage the use of vital services. This impacts more than equity,  but the overall population health and economic prosperity due to the cost of health care [6]. To rebuild trust in the health system by expanding access and encouraging utilisation of health services, it is necessary to centre equity and consider unique, individual needs. The last few years have highlighted the flaws of the US health system and have underpinned the continued medical disenfranchisement of vulnerable communities. It is imperative to address these issues now to develop the resilience of both the health system and of the population.