Explaining the persistence of health disparities: Social stratification and the efficiency-equity trade-off in the kidney transplantation system

Why do health disparities persist when their previous mechanisms are eliminated? Fundamental-cause theorists argue that social position primarily improves health through two metamechanisms: better access to health information and technology. I argue that the general, cumulative, and embodied consequences of social stratification can produce another metamechanism: an efficiency-equity trade-off. A case in point is kidney transplantation, where the mechanisms previously thought to link race to outcomes—ability to pay and certain factors in the kidney allocation system—have been greatly reduced, yet large disparities persist. I show that these current disparities are rooted in factors that directly influence posttransplant success, placing efficiency and racial/ethnic equity at cross-purposes.