Social issues in the United States—including mass incarceration, racism, and poverty—substantially contribute to health inequity, according to a series of new studies in the Lancet.
The Lancet's five-part "United States of Health" feature included studies assessing:
- Health care inequality generally;
- Population health and increasing income inequality;
- The relationship between the Affordable Care Act (ACA) and health care inequality;
- The relationship between structural racism and health care inequality; and
- The relationship between mass incarceration and public health.
The studies were conducted by academics and physicians at institutions such as University of California, San Francisco, Harvard T.H. Chan School of Public Health, and Cornell University.
Together, the studies paint a troubling picture of health care inequality in the United States—which is one of the most unequal countries in health outcomes among the 34 developed countries in the Organization for Economic Cooperation and Development, the researchers said. According to FierceHealthcare, several of the papers noted that so-called social determinants of health play a large role in perpetuating the country's health care inequality.
Among other conclusions on the relationship between income and health, the researchers found that:
- The life expectancies of the richest Americans are now 10 to 15 years longer than those with the lowest incomes;
- The 5 percent of Americans with the lowest incomes have seen essentially no gains in life expectancy since 2001—while middle- and upper-income Americans have gained 2 years;
- Based on current trends, the gap in life expectancy between the 20 percent of the country's population with the lowest incomes and the 20 percent with the highest incomes will increase by nearly 10 years in a single generation; and
- One-in-ten families with medical bill problems have declared bankruptcy.
The researchers argued that economic insecurity is an integral factor behind some of the country's biggest public health care crises, such as obesity and the opioid epidemic. According to Jacob Bor of Boston University School of Public Health, "Without interventions to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century health-poverty trap and the further widening and hardening of socioeconomic inequalities in health."
Impact of the Affordable Care Act
Although several of the studies found that health care inequality has increased markedly in recent decades, the study assessing inequality and the ACA found that the health care law had positive effects on inequality, including decreasing the uninsured rate and reducing the number of people who avoided care or had difficulty paying medical bills.
However, the researchers said many individuals in the country with the lowest incomes remain uninsured. According to the researchers, a substantially larger proportion of people with incomes below 100 percent of the federal poverty line (FPL) didn't have health insurance (25 percent) compared with those who had incomes at 200 percent or more of the FPL (7.6 percent) in 2015.
The study authors concluded that states' decisions not to expand Medicaid under the law are blunting the ACA's positive effect on health care inequality. And Adam Gaffney—lead author of the report on the ACA, physician at Cambridge Health Alliance, and instructor at Harvard Medical School—said Republican proposals to reform health care would increase inequality. "Rather than improve the health inequalities that remain a grave problem even in the era of the ACA, [regressive tax credits and Medicare privatization] would only make things worse. Real reform is now needed to take us towards a universal single-payer system," he said.
Health and income inequality are also significantly tied to race, according to one of the Lancet studies. For instance, in 2013, the median family income among non-Hispanic whites was 10 times larger than for Hispanics and more than 12 times larger than that of blacks.
Blacks also have significantly worse health outcomes in many cases. For instance, black infant mortality is twice as high as the rate of white infant mortality, according to a release.
The authors of the study on structural racism said these financial and health inequalities are tied to housing, employment, criminal justice, and other forms of discrimination. "Racial and ethnic health disparities in the United States are well documented, but structural racism is rarely discussed as a root cause," Mary Bassett, the commissioner of the New York City Department of Health and Mental Hygiene, said. She added, "If we don't address structural racism, health inequities will persist."
Noting that the United States has the highest rate of incarceration of any country at 743 per 100,000 people, the researchers pointed out that every aspect of the criminal justice system—from arrest to re-entry—influences health and communities. For instance, the researchers found that:
- Compared with non-incarcerated individuals, prisoners and former prisoners report higher rates of hepatitis C, hypertension, diabetes, substance misuse, and mental health disorders;
- Individuals on probation and parole have particularly high mortality rates;
- If incarceration in the United States had remained at its mid-1980s level, gains in life expectancy by 2005 would have been about 51 percent higher.
Christopher Wildeman at Cornell University said, "Soaring incarceration since the 1970s has profoundly affected health in the United States and, because of the uneven distribution of incarceration, the criminal justice system further contributes to racial health inequalities." He called for "sweeping reforms ... 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" (Minemyer, Fierce Healthcare, 4/7; Lancet release, 4/6; Murphy, Sacramento Bee/McClatchy, 4/7; Park, Time Health, 4/6).
How to address health inequity in your community
With the shift in health care to focus on optimizing the health of individuals and communities, health care organizations are creating new strategies to address health care disparities in access and patient outcomes.
Advisory Board has created the Health Disparities Initiative, which provides actionable resources on a series of strategic imperatives and special topics to achieve equity of care. Interested in seeing research or resources that address your biggest health equity problems?
Download our resource, "Building Community Partnerships to Reduce Disparities," which includes studies featuring providers who have successfully partnered with community organizations to address health disparities and social determinants of health. You'll also find tools that can guide your organization’s community partnership strategy.