Improving a Primary Good: Addressing Healthcare Inequality

Introduction

One sign of a flourishing society is when its people live long lives free of disease and disability. This fundamental link between health and well-being is universally recognized. Yet we find that even among many economically developed nations such as the United States, there is much to be desired in the health outcomes of its people. The Chicago Tribune did research in 2000 that was independently verified by the CDC that estimated that 103,000 deaths to linked to hospital infections occur each year in the United States, of which 3/4 are preventable (5). What may or may not be worse is that these poor health outcomes are more likely to affect certain parts of the population than others based on wealth-related factors. “People whose reported family incomes in 1980 were less than $5,000 in 1980 prices areestimated to have a life expectancy around 25 percent lower than thosewhose family incomes were above $50,000. (1)

While in the US there have been great advances in the past 20 years to improve society well-being such as better welfare and social security programs, improved technology and a (relatively) stronger economy, there is also increased disparity across a number of factors such as income and mortality. In what follows, I seek to outline in more detail the relationship between income, social status, mortality, and health as known to us from research in the social sciences – data that is informative but not always conclusive. I will then consider the societal challenges that arise from these relationships and discuss what outcomes we would wish to see from policy directed in this area. Finally, I will delve into decisions on policy and outline general criteria that would facilitate the outcomes I describe.

Analysis of Research into Health and Income

There are definite links between the health and socioeconomic status (SES) of individuals living either in developed or developing nations. Broadly speaking, the greater the disparity in the SES of a nation, the greater the disparities in health and mortality. However, this relationship has many qualifications.

We must begin by defining socioeconomic status – as social science research has indicated that looking at SES provides a more integrative understanding of what might typically be implied by income. Education, Income and Occupation typically represent the three key facets that indicate SES, and the relationship of each to health outcomes will be considered.

Income: The past several decades have seen a widening gap in what American’s earn each year. According to conventional Census numbers, the income share of the top fifth of households rose from 43.7 percent of total income in 1980 to 49.7 percent in 2002 which represented over four times the income share of the bottom two-fifths (6). The direct impact of low income is apparent – health care costs money and those with less to spend on health care will fare worse. The effects begin early in life: research has shown that in the first decade of life, doubling income levels leads to a roughly 20 percent reduction in mortality. (1), and continue onwards. When 44 million Americans are uninsured, (of which 60 percent are low-income families) the result is worse health outcomes due to reduced medical treatment. (3)

But beyond these simple metrics, income levels have a more subtle effect, but no less powerful effect on health outcomes. For instance, high infant mortality rates can be largely attributed to “lack of sanitation; malnutrition; low-qualityhousing and overcrowding; and lack of medical care including carebefore, during, and after childbirth” (7), which are all conditions seen in impoverished communities.

However, beyond a certain level, its not so much absolute wealth or poverty, but relative wealth or poverty that impacts health outcomes. For instance, researchers found that a state’s income inequality, as measured by the percent of state’s total income was held by the poorer half of the households, was “significantly associated with age specific mortalities and rates of low birth weight, homicide, violent crime, work disability, expenditures on medical care and police protection, smoking, and sedentary activity” (3). These trends were seen regardless of absolute value of the state’s average income level – suggesting that the relative inequality was what generated the poor health and mortality outcomes in the poorer half.

Education: The data suggests that education also plays a significant role in an individual’s health: for every additional year of education reduces an individual’s mortality rate (irrespective of age) by about 8 percent – and increases their earning potential by roughly the same amount (which as we’ve seen, improves health outcomes as well) (1). Another indication of education’s interconnection to income in predicting health outcomes can be seen in smoking research that shows that individuals are unaffected by income or education when they start smoking. However, more educated individuals are likely to attempt to quit, and of those want-to-be-quitters, the wealthier individuals are more likely to succeed. And thus the poorer, less-educated individuals are more likely to suffer the detrimental effects of smoking (3).

In general, people with less education are less likely to absorb public health information or even have access to health care in general: of the people who did not complete high school, four out of ten are uninsured (3). Studies on the impact of education, occupation and income on risk factors for cardiovascular disease demonstrated that when taken together, only education remained a significant predictor (2).

Occupation: People who are employed tend to be healthier than those who are unemployed, and the longer people are unemployed, the worse their health becomes.(3) Also, blue collar workers are more likely to get injured or ill from their job, and general strain is higher. Many blue collar workers live in cities, where housing quality is poorer, there is increased residential crowding, noise and air pollution – all of which affect health outcomes (3). Even at higher levels of income, we find that relative disparity among occupation levels can lead to differences in health outcomes. Studies done by Whitehal on British civil servants found that an employee’s position on the occupational hierarchy (or grade of employment) was stronger than income as a predictor of self-reported ill health and depression (2).

Research Summary: It is clear that an individual’s relative SES within a nation or state can provide a great deal of information regarding his or her future health levels and mortality rate independent of the wealth/income level of that nation or state. The lower the relative SES, the worse the absolute health outcomes. What’s exceptionally bad about this relationship is that it is cyclic: lower SES leads to worse health outcomes, which negatively impacts SES indicators. A reduction in a mother’s health, particularly in regards smoking and nutrition can predict her child’s teenage educational achievements and likelihood of being married, both indicators of SES. As we move to policy considerations, we must be careful to take this vicious cycle of SES and health into account.

Taking Research to Policy

To the extent that this research into SES and health can inform policy decisions, a discussion about the goals of policy is an important first step that will establish focus and priorities for policy-makers.

Policy Goals: One obvious goal would be to reduce health disparities. Many argue that this inequality in health outcomes is a unfair and undesirable outcome that should be prevented whenever possible. However this goal can lead to undesirable outcomes – the reduction of all health outcomes in order to reduce inequality, or the disincentive to develop medical treatment that could benefit people at higher income levels (treatments that would likely reduce in cost over time as to help people of all income levels).

My suggestion would be to set a baseline level of health that is periodically re-calibrated, ensure that all individuals reach this standard of health, and then focus on improving health outcomes for all people. This ensure that no one drops to an unacceptable level of health and that our first priority is to ensure for that bottom level outcome – but also encourages the development of medical treatment and broader public health policies that could benefit all or many individuals. The challenge would be in developing an objective baseline standard and finding a balance between getting everyone above baseline with broader health improvement policies. The first task could be accomplished through a government appointed task force, while the latter will largely depend on the thoughtfulness of policy makers, although perhaps particular criteria might help inform their decisions.

Criteria for Policy-Making: There are a number of criteria that emerge as relevant from the research done on health inequalities – these criteria should serve as guidelines for policy makers as the look to improve health outcomes of the entire population and especially the worst off.

  1. Reduce emphasis on hospital care. Research shows that hospital care and physician treatment, while important, is only a small piece of the puzzle when it comes to improving health.
  2. Broaden view of health improvement. Few people think of education policy as a means of improving public health, fewer consider city planning under the realm of health policy but the research indicates that both educating the public and designing safer and more vibrant communities will go a long way to improving health outcomes.
  3. Ensure health policies are developed with needs of low SES people. Our research findings suggest that people with low SES have more difficulty absorbing and responding to public health messages. This is just one example of the need to customize health policies to be more effective for people of low SES.
  4. Encourage policies that might reduce status comparison. While this recommendation is vague, it’s worth bearing in mind that health outcomes are dependent not just on absolute income, but on relative measures of status or position. Policies that somehow reduce the ability or desire for people to make such comparisons will have a better chance of improving health outcomes.

Conclusion

While there have been incredible advances in average income, and life expectancy in the past few centuries of humanity, in more recent years, there has been a growing divide among those who have little and those who have much in the way of wealth, education, and health. We must find an appropriate “standard of care” that is provided to all individuals, without limiting health improvement for the general population.

References

1) Deaton, Angus. “Policy ImplicationsOfThe Gradient Of HealthAnd Wealth” Health Affairs. March/April 2002.

2) Marmot, Michael. “The Influence Of IncomeOn Health: Views Of AnEpidemiologist”. Health Affairs. March/April 2002.

3) Newman, Katherine and Adler, Nancy E. “Socioeconomic Disparities in Health: Pathways and Policies” Health Affairs. March/April 2002

4) Wilkinson, Richard G. “Socioeconomic determinants of health: Health inequalities: relative orabsolute material standards?” British Medical Journal. February 22, 1997

(5) Berens, Michael J. “Infection epidemic carves deadly path: Poor hygiene, overwhelmed workers contribute to thousands of deaths”. Chicago Tribune. July 21, 2002

(6)U.S. Bureau of the Census, Income in the United States: 2002, Current Population Reports, Series P60-221, September 2003, p. 25.

(7) Kaplan GA, Pamuk E, Lynch JW, Cohen RO, Balfour JL. Income inequality and mortality in theUnited States: analysis of mortality and potential pathways.British Medical Journal 1996;312:999-1003

Written on 5/7/2009 for a Biology class at Stanford University

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