DECEMBER 2019 Health Inequity in the United States A Primer By José J. Escarce, MD, PhD University of California at Los Angeles Adapted from a keynote speech at the 20th Anniversary Conference of the Summer Undergraduate Minority Research (SUMR) Program University of Pennsylvania, July 30, 2019 By any measure, the United States has a level of health inequity rarely seen among developed nations. The roots of this inequity are deep and complex, and are a function of differences in income, education, race and segregation, and place. In this primer, we provide an overview of these distinctly American problems, and discuss programs and policies that might promote greater health equity in the population. —José Escarce, MD, PhD highest poverty rate at 18%, using the OECD measure. The What is Health Equity? U.S. also ranks last among OECD countries in a measure of income inequality (the Gini index, where higher indicates According to the World Health Organization (WHO),1 more inequality), which has grown considerably over the past 40 years (Figure 1).3 • Equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether Figure 1. Gini Index 1979-2016: Income Inequality has Grown those groups are defined socially, economically, demographically or geographically or by other means 42 of stratification. 41 40 Health equity then implies that everyone should have a fair 39 opportunity to obtain their full health potential and that no INDEX one should be disadvantaged from achieving this potential. 38 37 36 35 34 Where the U.S. Stands 1979 1986 1991 1994 1997 20002004 2007 2010 2013 2016 Among Nations Source: CEIC Data. United States US: Gini Coefficient (GINI Index): World Bank Estimate. Despite spending more on health care than all other countries in the Organization for Economic Cooperation and At the same time, the U.S. has what appears to be a Development (OECD), the U.S. has some of the poorest spectacularly inefficient health care system, spending far more health outcomes.2 Among 34 other OECD countries, the U.S. than the next closest country, which is Switzerland (Figure 2). ranks 28th in life expectancy and 33rd in infant mortality. A But it wasn’t always this way. The U.S. had always been near sizable portion of the poor outcomes in the U.S. is attributable the top of health care spending, but in the same range as peer to social determinants of health. Notably, while the U.S. has nations, until about 1980. And then something happened. the 11th highest per capita GDP ($59,532), it also has the While we always talk about the levels of spending, we tend 2 Health Inequity in the United States: A Primer not to talk about what’s happened over the last 40 years that health is shaped by these factors and how they affect our has made the U.S. separate so much from other countries. opportunities to adopt health life styles and behaviors, Economists have proposed various explanations, but debate including diet, and the material circumstances in which we live. on the issue remains. Health equity provides a lens through which to view the factors that influence health in the U.S. and an opportunity Figure 2. The Inefficient U.S. Health Care System: Health Care Cost (1970-2016) to develop solutions. In the next sections, we describe the observed relationships between health equity and income, 20 education, and race and segregation. 15 INCOME PERCENT OF GDP There are significant differences when we compare the health 10 outcomes of Americans with incomes below 100% of the poverty line and Americans with incomes above 200% of the poverty line. As examples, among many others, Americans 5 below 100% of the poverty line are:4 • Less likely to be in excellent or very good health 0 19701975 1980 1985 1990 1995 2000 20052010 2015 • More susceptible to develop coronary heart disease, hypertension, diabetes and stroke ■ Austria ■ Canada ■ Germany ■ Switzerland ■ United Kingdom ■ United States • More likely to have a physical limitation Source: Based on OECD.Stat data Life expectancy also varies by income level.5 The expected age at death among 40-year-olds is lowest for individuals with the lowest household income and increases as household However, while the health care system is important, health income increases (Figure 4). Notably, this is a continuous (and health equity) is in large part a function of social and gradient; it’s not the case that the expected age at death political context, and structural determinants such as social plateaus after one reaches a certain income threshold. class, education, occupation and income (Figure 3). Our Figure 3. World Health Organization’s Social Determinants of Health Conceptual Framework Socioeconomic & political context Material Social position Governance circumstances Distribution of health Social cohesion and well-being Education Psychosocial factors Policy Behaviors (Macroeconomic, Occupation Biological factors Social, Health) Income Gender Cultural and societal norms and values Ethnicity/Race Health Care System SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES Source: The World Health Organization Social Determinants of Health Conceptual Framework (CDC adaptation). 3 Health Inequity in the United States: A Primer Figure 4. Expected Age at Death Among 40-Year-Old Men and Women, These data examine life expectancy at age 40, but the by Household Income Percentile relationship between health and income begins at a very 90 young age.4 Figure 5 shows parents’ rating of their children’s Women health (1 is best, 5 is worst), at different levels of parental Expected Age at Death for 40-Year-Olds income. There is a line for kids age 0 to 3, 4 through 8, 9 85 through 12, and 13 to 17. The first noteworthy point is that Men even at age 0 to 3, income matters; the higher the child’s family income, the better the child’s health. 80 The second point is that income matters more as children get 75 older. The relationship between income and health begins Women, Bottom 1%: 78.8 years Women, Top 1%: 88.9 years when kids are little, continues, and grows over time. It’s not Men, Bottom 1%: 72.7 years surprising that we see pronounced differences at the end of Men, Top 1%: 87.3 years 70 the lifespan. 0 20 40 60 80 100 Household Income Percentile EDUCATION Source: Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., When compared with individuals who have bachelor’s Bergeron, A., & Cutler, D. (2016). The Association Between Income and Life Expectancy in the United States, 2001-2014. JAMA, 315(16), 1750-1766. degrees, individuals with only high school degrees:6 • Are less likely to be in excellent or very good health There is a 10-year difference in life expectancy between • Are at a higher risk for hypertension, diabetes, or stroke women in the top 1% of income and women in the bottom 1%, and the disparity is even greater among men, who have a • Are more likely to have a physical limitation 15-year gap between the highest and lowest incomes. Women • Have a shorter life expectancy at every income group live longer than men do, but the difference narrows among the highest income people. Figure 6 shows life expectancy, this time at age 25 rather than 40, by educational level.7 Women who have less than high Unfortunately, these trends are worsening over time. While all school education can expect to live 50 more years from the income groups gained in life expectancy since 2000, the gains age of 25, whereas similar men live an additional 44 years, have been greater for the highest earners. Consequently, the to age 69, on average. As with income, this is a continuous gap in life expectancy between the highest earners in society gradient: the more education you get, the better off you are. and the lowest earners is increasing. Rather than the lowest Also, as with income, educational gaps in life expectancy are earners slowly catching up, they’re falling further behind. increasing over time. Figure 5. The Origins of the Gradient Between Income and Health: Figure 6. Remaining Years of Life for U.S. Adults at Age 25 by Educational It’s There from Birth Attainment, 2005 2.25 ages 9-12 62 62 60 56 58 57 HEALTH STATUS (BETTER → WORSE) 50 51 52 ages 13-17 2.00 44 ages 4-8 1.75 ages 0-3 1.5 Less than High Some College Graduate High School School College Graduates Degree 8 9 10 11 Graduate Graduate LOG OF FAMILY INCOME (POOR → NON-POOR) ■ Women ■ Men Source: Case, A., Lubotsky, D., & Paxson, C. (2002). Economic Status and Health in Childhood: The Origins of the Gradient. American Economic Review, 92(5), Source: Hummer, R.A. & Hernandez, E.M. (2013). The Effect of Educational 1308-1334. Attainment on Adult Mortality in the United States. Population Bulletin, 68 (1). 4 Health Inequity in the United States: A Primer Figure 7. Expected Age at Death Among 40-Year-Old Men and Women, by Household Income Percentile Drug and alcohol poisoning Suicide Alcoholic liver disease and cirrhosis 60 60 high school or less 60 high school or less 40 40 high school or less deaths per 100,000 deaths per 100,000 deaths per 100,000 40 some college some college Some college 20 20 20 BA or more BA or more BA or more 0 0 0 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 Survey year Survey year Survey year Source: Case, A. & Deaton, A. (2017). Mortality and Morbidity in the 21st Century. Brookings Papers on Economic Activity, 397–476. The effect of education on health is particularly topical, given by an appreciable percentage, and much lower with regard the recent increase in the United States in death rates among to the probability of having a bachelor’s degree. Wealth middle-aged whites.8 The increase can partly be attributed disparities—the value of your assets, your home, the things to so-called “deaths of despair,” that is, deaths due to suicide, you own—are the biggest of all. alcohol consumption, and drug use. As shown in Figure 7, deaths of despair have been concentrated among whites who These disparities have health repercussions. Among many never attended college.8 other outcomes, compared to whites, African Americans:6 • Have a lower life expectancy Unfortunately, most recently deaths of despair have begun to spread to younger whites and to people of other racial groups • Have higher rates of infant mortality and ethnicities in the U.S., and other countries are beginning • Are less likely to be in excellent or very good health to see them as well. Educationally and economically, there • Are more vulnerable to obesity, coronary heart disease, are a number of people in these societies that have been “left hypertension, diabetes and stroke behind” and that’s having repercussions on their health. Life expectancy for African American men is about five years RACE less for men and three years less for women than their white Health, inequity, and race are inextricably linked. Some of this counterparts. Infant mortality is almost three times as high. can be explained by disadvantages in education and income. David Williams, a leading scholar in the country on issues For example, in 2017, the median household income for whites of health status and health disparities, points to residential was about $64,000, more than 50% higher than for African segregation as a fundamental cause of racial disparities in Americans. The poverty rate was twice as high for African health. The conceptual model in Figure 8, adapted from Americans. The chances of a high school degree were lower his work, explains how racism and residential segregation Figure 8. Racism, Racial Residential Segregation and Health 5 EXPERIENCE OF DISCRIMINATION Other forms of discrimination Racial differences in SES Racial differences in • Educational opportunities neighborhood environment • Employment opportunities • Housing quality Institutional and • Asset accumulation • Healthy food availability Health Racial residential • Pollution and crime personal racism segregation • Medical care outcomes • Stressors Source: Popescu, I., Duffy, E., Mendelsohn, J., Escarce, J.J., (2018). Racial Residential Segregation, Socioeconomic Disparities, and the White-Black Survival Gap. PLoS ONE 13(2). 5 Health Inequity in the United States: A Primer affect health outcomes through differences in educational Figure 10. Racial Gap in Survival vs. Segregation opportunities, employment opportunities, asset accumulation, and, of course, the neighborhood environment. Overall White-Black Survival Probability Difference Slope = 0.131 What does segregation actually look like? Figure 9 is a map P-value = <.0001 0.15 of Chicago, one of the most segregated cities in the U.S. The measure of segregation is the black-white dissimilarity index, which ranges from 0 to 1 and corresponds to the proportion of African Americans who would have to move to fully integrate 0.10 the city, that is, to make every neighborhood have the same proportion of African Americans and whites. 0.05 Figure 9. Segregation Map of Chicago, 2010 0.00 ■ Black ■ White 0.2 0.3 0.4 0.5 0.6 0.7 0.8 ■ Hispanic Dissimilarity Index ■ Asian Escarce, J.J. (2016, January). Residential Segregation, the White-Black Income ■ Other Gap, and White-Black Disparities in Premature Mortality. Presented at the National D=.76 Academy of Social Insurance 28th Annual Policy Research Conference Programs and Policies A number of program and policies have shown promise in reducing the health equity gap in the U.S., even if they are not primarily focused on health. The Earned Income Tax Credit (EITC) is money that low- income working families get from the Federal government, similar to a negative income tax. If you work but make less than a certain amount, you actually receive money from the Federal government, and how much money you get depends Source: Fisher, E. (2011 March 26). Race and Ethnicity 2010: Chicago. on how much you make and how many children you have. The amount you receive increases for a while, then flattens out for a while, and then decreases to zero at higher incomes. A recent study examined the effects of segregation on one If you don’t have children, you get very little, about $500 a measure of life expectancy: the chances that a 35-year old year, but if you have three children, you get up to $6,500 or will live to 75.9 For whites, the chances are 69%; for African so. For a family making, say $40,000, $6,500 is a lot of money. Americans they are 59%. Most notably, survival for whites is unaffected by the level of integration. By contrast, the The EITC, which is a transfer of money to working people, probability that a 35-year old African American survives has profound health effects on the people who receive it, as to age 75 decreases for African Americans as the degree shown in Figure 11.10 of segregation increases. Figure 10 depicts the relationship between segregation and survival from age 35 to age 75 in 122 The Food Stamps Program, which provides a voucher for big metropolitan areas in the United States. The graph shows food for all families who qualify by income, also functions that the gap increases from about 7 percentage points in the as a cash transfer.11 People were spending money on food least segregated cities to nearly 15 percentage points in the anyway and the food stamps allow them to use their money most segregated. for something else. It is similar in this way to the EITC, although more people receive it and the amounts are lower. 6 Health Inequity in the United States: A Primer phenomenon also seen with early childhood interventions. Figure 11. Effects of Income Transfer on Maternal and Two preschool interventions have been evaluated in Neonatal Health: Earned Income Tax Credit randomized trials, and have shown impressive long-term results. Maternal health: •  Self-rated health From 1962-1967, The Perry Preschool Project offered high- quality preschool program for African American children from •  Days in poor mental health low-income families in East Lansing, Michigan. As shown in •  Risky biomarkers Figure 12, at age 40, participants reported significant health benefits compared to those who were not in the program.14 Infant health: Men were less likely to be a daily smoker, less likely to be a •  Low birth weight heavy smoker, and smoked less cigarettes per day. Women reported significantly higher rates of physical activity. Effect of treatment All births Figure 12. Long-term Effects of Preschool Education and Parenting 2nd child  0.2% * Guidance on Health Behaviors: Perry Preschool Project 3rd child  0.5% ** ControlTreatment African-American births GroupGroup 2nd child  0.3% * Men (age 40) 3rd child  1.0% ** Daily smoke 53% 33% * *p<.05, **p<.01 Heavy smoker 26% 7.1% ** No. cigarettes per day 6.5 3.7 ** Source: Evans, W. N. & Garthwaite, C. L. (2014). Giving Mom a Break: The Impact of Higher EITC Payments on Maternal Health. American Economic Journal: Economic Women (age 40) Policy, 6(2), 258-90. Physical activity 4.5% 38% *** Remarkably, the health effects are substantial for adults who *p<.10, **p<.05, ***p<.01 received food stamps as children, or whose mothers received food stamps while pregnant.12 These adults have garnered the following health benefits: Source: Heckman, J.J., Pinto, R., & Savelyev, P. (2013). Understanding the Mech- anisms Through Which an Influential Early Childhood Program Boosted Adult • Lower rates of obesity (men and women) Outcomes. American Economic Review, 103(6), 2052-2086. • Lower rates of stunted growth (men and women) • Lower rates of metabolic syndrome (men and women) Later in the 1970s, the Cadillac of preschool programs, the Abecedarian Project began in Raleigh, North Carolina. It • Higher rates of self-rated health (women) was a powerful wraparound intervention that also provided families with medical care, well child visits, nutritional Minimum Wage Laws, another form of money transfer, assistance, and preschool. Kids were in preschool for nine have also been shown to provide health benefits to low- hours a day, five days a week, 50 weeks a year. They were income workers. Although this research is in its early stages, given healthy meals, and their parents were coached on how documented benefits include:13 to raise their children in healthier ways. • Reduction in smoking Researchers compared the long-term health outcomes • Improvement in mental health between children who were in the program and children who • Decrease in non-drug suicides were not (Figure 13).15 When followed into their 30s, men who • Overall increase in general health participated in the preschool and nutritional program reported taller heights and higher HDL cholesterol, as well as lower: • Fewer missed work days due to illness • Body mass index (BMI) The data on the EITC and the Food Stamps Program • Rates of metabolic syndrome demonstrate the long reach of a policy, many years later, a 7 Health Inequity in the United States: A Primer • Framingham risk score (predictor of cardiac events in the Medicaid Expansions in the late 80s and early 90s next 10 years) broadened Medicaid coverage to pregnant women with • Incidence of vitamin D deficiency incomes up to 185% of poverty, and slowly expanded coverage to children with similar incomes as well. The • Rates of hypertension expansions have had substantial positive health effects for Women who participated in the program reported the various groups. following health benefits in their 30s: • Medicaid expansions for pregnant women resulted • Lower Framingham risk score in reduced incidence of low birth weight babies and • Higher physical activity levels reduced infant mortality.16 Further, the beneficial effects on children of extending insurance coverage to low- • More fruit servings per day income pregnant women continued at least until the children reached age 19, most significantly among African Americans. These effects included: Figure 13. Long-term Effects of Intensive Preschool, Nutritional • Lower rates of chronic conditions, including diabetes Support and Healthcare Access on Health and Health Behaviors: Abecedarian Project and hypertension ControlTreatment • Fewer reports of psychological distress GroupGroup • Reduced hospitalizations for chronic conditions Men (age 30s) Height (m) 1.74 1.79 ** • Medicaid expansions for children aged 8 to 14 lead to a reduction in hospitalizations for chronic conditions BMI 33.3 29.2 * among African Americans at age 25.17 Hypertension 56% 21%** HDL cholesterol (mg/dL) 42.0 53.2 * Finally, there is the Affordable Care Act (ACA), passed Metabolic syndrome 25% 0% *** in 2010, for which the long-term effects cannot yet be measured. This research on the ACA is very new, but already Framingham risk score 7.0 4.9 ** there is evidence of health benefits from the Medicaid Vitamin D deficiency 75% 37% ** expansion under the ACA. For adults ages 19-64, studies18,19 have demonstrated that Medicaid expansion was associated Women (age 30s) with: Framingham risk score 1.5 1.1 * • Better self-rated health Physical activity 7.1% 32% ** • Reductions in days in poor mental health Fruit servings per day 0.3 0.8 *** • Overall reduction in mortality *p<.10, **p<.05, ***p<.01 The consistent improvements in mental health from cash transfers or insurance expansions are especially noteworthy, Source: Campbell, F., Conti, G., Heckman, J.J., Moon, S.H., Pinto, R., Pungello, E., and suggest that anxiety and worry are constant companions & Pan, Y. (2014). Early Childhood Investments Substantially Boost Adult Health. Science, 343(6178), 1478-1485. of not having enough money. Anxiety and worry, of course, can also affect physical health. It’s worth underscoring that these are just the health outcomes, because the outcomes with regard to personality traits, resilience, self-management are all remarkable, as are the educational and economic outcomes. Nonetheless, the health outcomes themselves are pretty amazing. Summary We’ve reviewed programs that have had a substantial impact The U.S. ranks poorly among OECD countries in life on health, although they were not designed specifically as expectancy and infant mortality. There’s a high, and growing, health programs. Naturally, describing the health effects of income inequality and we outspend our peer nations on insurance expansions is also important, keeping health equity health care. Not surprisingly, there are inequities in health, in mind. based on income, educational attainment, race, and place. 8 Health Inequity in the United States: A Primer These inequities, or at least the ones based on income 8. Case, A. & Deaton, A. (2017). Mortality and Morbidity in the and education, appear to be growing over time. Policies to 21st Century. Brookings Papers on Economic Activity, 397–476. improve material resources for the poor, support parents and especially children, early in life, and extend health insurance 9. Popescu, I., Duffy, E., Mendelsohn, J., & Escarce, J.J. (2018). coverage have shown promise in reducing health inequities. In Racial Residential Segregation, Socioeconomic Disparities, and the White-Black Survival Gap. PLoS ONE, 13(2). the big picture, however, fundamental structural issues in our society that shape people’s opportunities are by far the most 10. Evans, W. N. & Garthwaite, C. L. (2014). Giving Mom a Break: important. It’s likely that the only way to achieve health equity, The Impact of Higher EITC Payments on Maternal Health. rather than simply reduce inequities, is to tackle and solve American Economic Journal: Economic Policy, 6(2), 258-90. these structural issues. 11. U.S. Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program (SNAP). Available from: https://www.fns.usda.gov/snap/supplemental-nutrition- assistance-program 12. Hoynes, H., Schanzenbach, D.W., & Almond, D. (2016). Long-Run Impacts of Childhood Access to the Safety Net. American Economic Review, 106(4), 903-34. REFERENCES 13. Leigh, J.P., Leigh, W.A., & Du, J. (2018). Minimum Wages and Public Health: A Literature Review. Preventive Medicine, 118, 122-134. 1. World Health Organization. Equity. Retrieved from https://www. 14. Heckman, J.J., Pinto, R., & Savelyev, P. (2013). Understanding who.int/healthsystems/topics/equity/en/ the Mechanisms Through Which an Influential Early Childhood Program Boosted Adult Outcomes. American 2. OECD (2015), OECD.Stat, (database). Available from: Economic Review, 103(6), 2052-2086. https://stats.oecd.org/ 15. Campbell, F., Conti, G., Heckman, J.J., Moon, S.H., Pinto, R., 3. CEIC Data. 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JAMA, 315(16), 1750-1766. 18. Cawley, J., Soni, A., Simon, K. (2018). Third Year of Survey Data Shows Continuing Benefits of Medicaid Expansions for 6. Cutler, D. & Lleras-Muney, A. (2008). Education and Health: Low-Income Childless Adults in the U.S. Journal of General Evaluating Theories and Evidence. In: Making Americans Internal Medicine, 33(9):1495-1497. Healthier: Social and Economic Policy as Health Policy. New York: Russell Sage Foundation. 19. Miller, S., Altekruse, S., Johnson, N., & Wherry, L.R. (2019). Medicaid and Mortality: New Evidence from Linked Survey 7. Hummer, R.A. & Hernandez, E.M. (2013). The Effect of and Administrative Data. NBER Working Paper 26081. Educational Attainment on Adult Mortality in the United States. Population Bulletin, 68(1). 9 Health Inequity in the United States: A Primer COLONIAL PENN CENTER 3641 LOCUST WALK PHILADELPHIA, PA 19104 LDI.UPENN.EDU @PENNLDI