April 11, 2017 – The life expectancy of the wealthiest Americans, which now exceeds that of the poorest Americans by 10 to 15 years, continues to grow, according to a series of papers published in The Lancet, one of the world’s oldest and most respected medical journals. This “survival gap” is a result of America’s fractured, for-profit health system, as well as its rapidly growing economic inequality, racial segregation and mass incarceration, which is unique among industrialized nations, researchers say.
These topics and several others are discussed in a five-paper series in The Lancet called “America: Equity and Equality in Health,” featuring new data and analysis by prominent U.S. health researchers, as well as a special commentary by Senator Bernie Sanders, I-Vt., in which he calls for a “Medicare for All” single-payer system.
Dr. David Himmelstein, the lead author of the series, says: “Today, 43 million Americans are poor, and although the Affordable Care Act has nearly halved the number of people without insurance, 29 million Americans, many of them poor or near-poor, remain uninsured. Health inequalities are more entrenched than ever, and rather than address them, the U.S. health care system often exacerbates them. In order to tackle health inequalities in the U.S., it is essential that we move towards a non-market financing system that treats health care as a human right.” Himmelstein is an internist, professor of public health at the City University of New York (CUNY) at Hunter College, lecturer in medicine at Harvard Medical School and co-founder of Physicians for a National Health Program.
In his commentary, Sen. Sanders emphasizes the links between economic inequality and health outcomes, stressing the urgent need for a universal health program covering all Americans. He writes: “Such inequality continues to be one of the greatest moral and economic issues of our time. It’s also a huge health issue. … The USA has the most expensive, bureaucratic, wasteful, and ineffective health care system in the world. Medicare-for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions in medical costs.”
The researchers of the five studies are chiefly physicians and public health researchers holding prominent positions at the CUNY, Harvard Medical School, Harvard’s School of Public Health, Boston University School of Public Health, Cornell University, Yale School of Medicine, and several other institutions, including the New York City Department of Health and Mental Hygiene.
Selected highlights of the five studies appear below, followed by “Key Facts” on health inequalities in the U.S. All articles contain extensive data, tables, graphs, and key takeaways from the The Lancet’s editors. For more information, visit www.lancet.com/us-health.
America: Equity and Equality in Health – a new Series from The Lancet
Study 1. “Inequality and the health-care system in the USA,” by Samuel L. Dickman, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.
Since 1986, the top 0.1 percent of American households has accumulated nearly half of all new wealth, and now controls as much wealth as the bottom 90 percent, whose share has fallen steadily. As top incomes have risen, so has extreme poverty. More than 1.6 million households in the U.S, including 3.5 million children, survive on incomes of less than $2 per person per day – the World Health Organization’s definition of extreme poverty; this number has more than doubled since the 1990s.
As economic inequality has deepened, so too has inequality in health. Almost every chronic condition, from stroke to heart disease and arthritis, follows a predictable pattern of rising prevalence with declining income. The life expectancy gap between rich and poor Americans has been widening since the 1970s, with the difference between the richest and poorest 1 percent now standing at 10.1 years for women and 14.6 years for men.
Instead of reducing income-based disparities in health, the market-based American health care system often exacerbates them by its very design. Low-income Americans have worse access to care than do wealthy Americans, partly because so many remain uninsured despite coverage expansions of the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health care resources devoted to care of the wealthy has risen.
The uninsured (who are disproportionately poor) pay for much of their care out of pocket and, because they do not have insurers’ negotiating leverage, are charged the highest prices. One in four adults under the age of 65 reported problems paying medical bills; 34 percent of insured Americans with difficulty paying medical bills were unable to pay for food, heat, or housing, 15 percent took out high-interest payday loans, and 42 percent took on extra jobs or worked additional hours to pay medical bills.
Study 2: “The Affordable Care Act: implication for health-care equity,” by Adam Gaffney, M.D., and Danny McCormick, M.D., M.P.H.
Despite the reforms promised by the Affordable Care Act (ACA), financial barriers to care persist and might be worsening. While the ACA has nearly halved the number of Americans without health insurance, the high cost of co-payments, deductibles and co-insurance still drive many insured households into debt, even bankruptcy. The ACA’s Medicaid expansion targeted the poorest Americans, but 19 states – mostly southern states with large minority populations and poor records of health care access – chose to opt out. Even if the ACA were not altered or repealed, 28 million people would remain uninsured in 2024.
“Republican proposals focus on market-based reforms that would slash federal funding for Medicaid, replace the ACA’s subsidies with regressive tax credits, and further privatize Medicare,” says Dr. Adam Gaffney, a pulmonary specialist at Cambridge Health Alliance and Harvard Medical School. “Rather than improve the health inequalities that remain a grave problem even in the era of the ACA, this approach would only make things worse. Real reform is now needed to take us towards a universal single-payer system.”
Study 3: “Structural racism and health inequities in the USA: evidence and interventions,” by Zinzi D. Bailey, Sc.D., Nancy Krieger, Ph.D., Madina Agénor, Sc.D., Jasmine Graves, M.P.H., Natalia Linos, Sc.D., and Mary T. Bassett, M.D.
Health and health equity are substantially influenced by the places where people live, work, play, and pray. In the U.S., high levels of racialized economic segregation and structural racism are key determinants of public health. The ongoing residential segregation of African Americans is associated with adverse birth outcomes, such as an infant mortality rate that is twice as high for African Americans than it is for whites. Marginalized groups also face an increased exposure to air pollutants, decreased longevity, increased risk of chronic disease, and increased rates of homicide and other crime. Residential segregation also affects health care access, utilization, and quality at the neighborhood, health care system, provider and individual levels.
“Racial and ethnic health disparities in the United States are well documented, but structural racism is rarely discussed as a root cause,” says Dr. Mary T. Bassett, commissioner of the New York City Department of Health and Mental Hygiene. “Structural racism refers to all the ways in which systems foster inequitable outcomes, whether in housing, education, employment, media, health care or the criminal justice system. All have profound effects on health. If we don’t address structural racism, health inequities will persist.”
The authors point to several potential solutions to improve health equity by targeting structural racism, including community programs to address housing and access to health care; policy reform to reduce sentencing laws and imprisonment; and training the next generation of health professionals.
Study 4: “Mass incarceration, public health, and widening inequality in the USA,” by Christopher Wildeman, M.D., and Emily A. Wang, M.D.
On any given day, the U.S. incarcerates more of its citizens (2.2 million) and at a higher percentage (7 percent of the population) than any other country in the world. Mass incarceration shapes inequality in American health, disproportionately affecting African American communities where one in three black men will be imprisoned in their lifetime, nearly six times the rate of white men. An African American child born in 1990 had a 25.1 percent chance of having a father sent to prison; for those whose fathers did not finish high school, the risk was roughly double that, at 50.5 percent. Nearly half of black women currently have a family member or extended family member who is in prison.
Incarcerated individuals have increased prevalence of infectious disease (including sexually transmitted diseases, HIV, and hepatitis C), chronic medical conditions (such as hypertension, diabetes, and asthma), substance abuse and mental health disorders. Upon release, they earn 30 percent less than similar individuals who have never been imprisoned, further compounding the health-poverty trap.
Interestingly, correctional facilities provide many incarcerated adults with their first access to preventive and chronic medical care, since prisons and jails are some of the only places in the U.S. where health care is guaranteed by law. An estimated 40 percent of individuals with chronic medical conditions are diagnosed with a chronic condition while incarcerated, and 80 percent report seeing a medical provider while incarcerated. These gains are short-lived, however, since recently-released inmates are less likely to have a primary care physician and are at a disproportionately high risk of mental health problems.
“Overcrowding, high costs and aggressive policing have led to increasing recognition that mass incarceration has failed,” says Dr. Christopher Wildeman of Cornell University. “But, sweeping reforms are needed to reduce incarceration of technical parole violators, expand community corrections for low-level property and drug crimes, and medical paroles for elderly or sick inmates, in addition to expanded access to health care for individuals affected by the criminal justice system.”
Because the U.S imprisons many more of its citizens than do other developed democracies, mass incarceration might have contributed to the country’s lagging performance on health indicators such as life expectancy. One study suggests that U.S. life expectancy would have increased 51.1 percent more and infant mortality would have fallen 39.6 percent more from 1983 to 2005 if incarceration had remained at the mid-1980s level.
Study 5: “Population health in an era of rising income inequality in the USA: 1980-2015,” by Jacob Bor, Sc.D, S.M.; Gregory Cohen; and Sandro Galea, M.D., Ph.D.
Incomes for poor and middle-income Americans have barely changed since the 1970s and, adjusted for inflation, have actually declined since 2000. Poverty has emerged as an increasingly important risk factor for mortality in American adults, and the expanding “survival gaps” between rich and poor cannot be explained away by individual risk factors such as smoking, obesity and substance abuse.
The survival gap widened in the 2000s, as life expectancy between 35 and 75 years of age increased for wealthy men and women, but did not change for poor men and actually declined for poor women, as measured by both income and level of education. Life expectancy for white Americans without a high school diploma dropped by 5.3 years for women and 3.4 years for men. The increase in deaths from poisonings, suicide, and liver disease together accounted for half of the total increase in mortality in this group.
The life-expectancy gap between college-educated Americans and those with less than a high school education increased by 0.8 years for men and 2.6 years for women from 1990 to 2008. However, the gains in survival enjoyed by white Americans with at least a high school education were not experienced by African Americans, suggesting that the health benefits of education might be cancelled out by factors associated with race and ethnicity such as structural racism.
The authors provided several reasons for the drop in health outcomes for low-income and lesser-educated Americans: (1) less access to technological innovations in medicine and information about complex health risks and preventive behaviors; (2) increasing geographical segregation that creates inequalities in access to health care; (3) reduced economic mobility and increased persistence of poverty; (4) rapidly increasing incarceration rates; and (5) the erosion of public subsidies for health insurance and other health inputs, and increasing exposure to market prices.
The American health care system exacerbates these problems. Even for those with health insurance, rising deductibles and co-payments are shifting more of the costs of care onto users. Since the early 2000s, health spending for wealthier Americans has soared, whereas expenditures have risen modestly for the middle class and actually fallen for those with low incomes, a health-poverty trap driven by medical cost.
Without immediate interventions to reduce inequality, U.S. may see the emergence of a 21st century “health-poverty trap” as economic insecurity can lead to poor health, and poor health can further limit economic productivity, bankrupt households and impoverish families.
KEY FACTS: Health inequalities in the U.S.
- The U.S. is one of the most unequal countries in the OECD – only Chile, Turkey and Mexico are more unequal.
- The life expectancy gap between rich and poor is among the highest in developed countries. The richest 1 percent of Americans live 10-15 years longer than the poorest 1 percent.
- The life expectancy gap has increased in recent decades, with poverty an increasingly strong risk factor for early death.
- Many people forgo medical care altogether: 39 percent of low income Americans reported not seeing a doctor because of costs, compared to 7 percent in Canada and 1 percent in the U.K.
- The U.S. health care system is the most expensive of any other country, yet people with serious illness commonly face financial hardship – 1 in 10 families with medical bill problems have declared bankruptcy.
- The poorest fifth of American spend 6 percent of their income on private insurance – nearly twice what the wealthiest fifth pay at 3.2 percent.
- The ACA significantly reduced the number of people who are uninsured – from 48.6 million in 2010, to 28.6 million in 2015, mostly through Medicaid expansions which Congress recently threatened to roll back.
- Before the 2014 implementation of the ACA, in 2012 43 percent of adults avoided needed care and 41 percent had medical bill difficulties, down to 36 percent and 35 percent in 2014.
- In 2015, inequalities remain: 25.2 percent of poor Americans are uninsured, compared to 7.6 percent of non-poor Americans; 27.7 percent for Hispanics, 14.4 percent for non-Hispanic blacks and 8.7 percent for non-Hispanic whites.
- U.S. life expectancy would have increased 51.1 percent more and infant mortality would have fallen 39.6 percent more from 1983 to 2005 if incarceration had remained at its mid-1980s level.
Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 21,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the studies or commentary described above.