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You Can Thank Racism, Mass Incarceration, and Our Health System for the Survival Gap Between the Rich and Poor

A new series of papers (and commentary from Bernie Sanders) lays out the problem.

Nick Keppler

Nick Keppler

Charlie Leight / Getty Images

The United States' for-profit healthcare system not only fails miserably to offer the same life-extending treatments to the poor as it does the rich, but it also reinforces racial and socioeconomic disparities, according to a wide-ranging five-part series published in the medical journal The Lancet

Income inequality, systematic racism, and mass incarceration have health effects that are cutting lives short, say study authors, who analyzed an array of existing research on the relationship between certain sociological factors and health. 

"Poor people, who can least afford it, pay a higher percentage of their income for healthcare for poorer results. The rich spend less on healthcare and are generally healthier and have less need," says David Himmelstein, a lecturer in medicine at Harvard Medical School, professor of public health and health policy at the City University of New York, and lead author of the series.

The authors quantified the "survival gap" between rich and poor. While middle- and high-income people have seen their life expectancy increase by two years since 2001, while the poorest 5 percent of Americans have seen no gains. Today, the wealthiest 1 percent of Americans live 10 to 15 years longer than the poorest 1 percent. But these inequities don't just affect the very highest and lowest earners: the authors predicted that, based on current trends, the lifespan gap between the poorest 20 percent and the wealthiest 20 percent will soon grow from 5 years to 13 years. 

There are many interconnected reasons for health inequities, according to the study. The very poorest are suffering a lot more; 1.6 million households in the US survived on incomes of less than $2 per person per day in 2011. That's the World Health Organization's definition of extreme poverty, and the number in the US has doubled since the 1990s. 

The poor face a number of barriers to good health and a long life, Himmelstein says: Residential segregation can often mean substandard housing with greater exposure to air pollution, and less access to fresh food in the neighborhood and in underfunded public schools. The public health hazards affecting them are more likely to be overlooked, too, as seen in the water crisis in Flint, Michigan. "Also, despair is a real factor," he adds. "There is a ballooning of suicides and drug overdoses."

Although lower-income people face more health hazards than the well-heeled, the poor are less likely to have access to healthcare. The passage of the Affordable Care Act, aka Obamacare, did cut the uninsured rate from 48.6 million in 2010 to 28.6 million in 2015, but those 28 million remaining uninsured are more likely to be poor. In fact, 25.2 percent of Americans below the federal poverty line had no health insurance in 2015, compared to 7.6 percent of those above it. Himmelstein and his co-authors partially blame the 19 states that opted out of the law's Medicaid expansion, which would have allowed people with incomes slightly above the poverty level to get Medicaid. Many of them are southern states with large minority populations and that have a history of insufficient healthcare options. 

Americans of lesser means are also more likely to delay seeking medical care because of expense than their income peers in countries with universal healthcare. In a study released the same year the ACA was passed, 39 percent of Americans with a below-average income reported not seeing a doctor because of cost, compared with 7 percent of poorer-than-average Canadians and 1 percent of Britons on the humbler end of the spectrum. Lack of treatment feeds chronic conditions, like heart disease, depression, and diabetes. 

One paper in the series looked at the impact that our incarceration rate has on life expectancy. Here in the good ol' US of A, there were 743 imprisoned persons per 100,000 people in 2005, which is the highest of any developed country (second-place New Zealand has 173 per 100,000 people). Prisoners and ex-prisoners have higher rates of HIV, hepatitis C, high blood pressure, diabetes, substance use, and mental health disorders. Also, those on probation and parole have particularly high mortality rates. 

"But the impact is on whole communities," Himmelstein says. People in prison can't work jobs that would extend health benefits to their family members and and they aren't contributing incomes that their families could spend on healthcare, food, and housing. As with income inequality, people of color are disproportionately affected: The annual rate of incarceration for black men is 3.8 to 10.5 times higher than for white men. The study concludes that had the incarceration rate remained what it had been in the mid-1980s, US life expectancy would have increased by an additional 51 percent and infant mortality would have fallen by an additional 40 percent.

Unusual for a medical journal, the series also includes commentary written by a politician, Senator Bernie Sanders of Vermont. Sanders wrote that income inequality "continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue…Life expectancy in the USA is far lower than in most other wealthy nations, largely because of the widening health gap between rich and poor Americans, and stark and persistent racial inequalities," adding that "health care is not a commodity. It is a human right."

The researchers suggest that the problem needs a public policy solution—namely a universal, government-funded healthcare program. This is also called "single-payer" or "Medicare for all," and the payer would be the government instead of any of the dozens of insurance companies that exist now. The arguments for single-payer systems are that everyone gets coverage and the government can negotiate lower drug prices because pharmaceutical companies basically have to accept their terms.

The Trump administration and Republican Congress seem bent on reversing progress toward decreasing the number of uninsured people through legislation, but Himmelstein says he sees both short- and long-term hope for single-payer coverage.

Himmelstein, co-founder of Physicians for a National Health Program, says that doctors have been forced into the political arena. "Public policy invades the examination room every day," he says. "I never intended to get involved but it invaded my space." He said he's dealt with patients with worsening conditions shuffled from private, expensive hospitals and Medicaid recipients who can't get medications they need or appointments with specialists. 

The Republican "repeal and replace" bill, which would have rolled back the Medicaid expansion and increased the number of uninsured by 24 million, failed to pass. A universal healthcare proposal is picking up Democratic support in the House of Representatives and Sanders is set to introduce a version in the Senate, making it a topic of political discussion. 

"A majority of people want it," Himmelstein says, referring to a 2016 Gallup poll which found that 58 percent of people supported replacing Obamacare with a universal healthcare system. "We see how quickly abrupt political change can happen. Fifteen years ago, gay marriage looked impossible."

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