A series published in The Lancet recently investigated the effect of income inequality on the health of Americans. While incomes for those in the top have grown, extreme poverty has also grown in the US. In fact, more than 1.6 million households in the US survive on less than $2 per day; a number double that of the 1990s. The cycle is not likely to be broken either, barring major social change. Differences in aspects ranging from zoning laws, access and quality of education, and inheritance laws continue these inequalities through generations, making it more difficult to rise out of poverty.
The series kicks off with an introduction by Vermont Senator, Bernie Sanders. While his whole article is excellent, this paragraph stuck out to me:
Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. 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 of dollars in medical costs.
One consequence of widening income inequality is in access to healthcare. Prior to the Affordable Care Act, 39% of below-average income Americans reported not seeing a doctor because of cost. This is almost 5.5 times more than low-income Canadians (7%), and 39 times higher than those in the UK (1%). Even within the US there are wide disparities, with low-income adults in Southern states being twice as likely to face cost-related barriers compared to those in Maine and Massachusetts. These barriers not only have impact in them seeking care to begin with, it can also impact their ability to continue and sustain treatment. For example, eliminating medication co-payments among patients who had a myocardial infarction resulted in a 35% decrease in future events, as well as a 70% reduction in total cost.
Many Americans pay for their own care, and are faced with an impossible choice between healthcare or putting food on the table, and 19% of adults in the US who received prescriptions in 2014 could not afford to fill them. In 2015, 25% of Americans below the age of 65 reported difficulty paying medical bills, and over half owed more than $2500. Meanwhile, millions of middle-class families have been bankrupted by illness and medical bills, to the point where some hospitals are discussing costs with patients prior to treatment. This has ramifications for their ability to afford food, heat, or housing costs, with some taking on high-interest payday loans or working additional hours to make up the deficit. Perhaps most concerning though, is how most are skipping or delaying medical care, which in turn perpetuates this cycle of poorer health outcomes.
The series continues, with sections on the Affordable Care Act, structural racism, mass incarceration, and finally population health as it relates to income inequality. While some of these issues are a little outside the realm of what one would consider “health” issues, these are all determinants of health, and impact our ability to live a healthy life to the fullest. Deepening our understanding of determinants of health will allow for us to generate data and information that can be used for policy and planning purposes.