How America's Outrageous Income Inequality Is Literally Killing Us
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Yet who would ever choose to face this pattern of competing health risks across their life course? It’s far more important to have a good chance to become elderly in the first place than to embrace the tiny chance of becoming a centenarian in the unlikely event you’re not already dead by sixty-five.
The vast disparities in health and longevity that exist between the races in the United States violate a fundamental idea of justice that we all carry with us at least to some degree. It is the idea of justice as fairness, of what kind of world we would choose to live in if, as the philosopher John Rawls framed it, we were all impartially situated as equals before being born and did not know what our station in this life would be. A society that resists ending the preventable causes of these racial disparities in heath is a society resisting justice.
But what are those preventable causes, and what could or should be done about them? To answer that question, let’s consider another thought experiment.
Imagine if, before you were born, you were told that you could choose to be born either black or white in America, but if you chose to be white you would live in poverty and if you chose to be black you would be in the lower-middle class. In this thought experiment, you wouldn’t know anything about what our world is actually like except for estimates of life expectancy for different categories of people.
Those estimates would tell you that choosing to be white would bring you very little, if any, advantage to health if you were also poor. For example, according to data developed by the Robert Wood Johnson Foundation, approximately 35 percent of whites living below the poverty line report themselves to be in only poor or fair health. This is quite close, after we adjust for age differences, to the 32 percent of poor blacks who report fair or poor health. (See chart above.)
Meanwhile, the health status of both blacks and whites improves dramatically with higher income while the gap between them remains small. Among blacks and whites living at just four times the poverty rate, for example, the percent who report poor or fair health drops to 8 percent and 6 percent respectively. Your race per se, in other words, plays little role in predicting your health compared to your income.
What explains the residual difference in the health status of blacks and whites who have the same-size pay check? Researchers suggest it may reflect in part the reality that at any given income level, blacks tend to have fewer assets than whites, such as home equity and financial savings. A black family earning, for example, $50,000 in income is less likely to own its own home, less likely to have received an inheritance, and more likely to be encumbered by debt than is a white family with the same income. (See Thomas J. Segrue, “ A House Divided.”) Middle-class black families are also more likely than middle-class white families to bear the health consequences of having lived in poverty in the past.
The gap in health status may also reflect the fact that among families with similar levels of income, as well as educational attainment, blacks are more likely than whites to live in neighborhoods with higher concentrations of crime, poverty, pollution, liquor stores, “junk food” outlets, and inferior health care. (See “ To Live Longer, Move to a New Zip Code.”) Conscious or unconscious bias among health care providers may also be at work in explaining the racial health gap, though your chances of receiving substandard health care in the United States vary far more according to where you live than according to the color of your skin. (See “ Color-Blind Medicine?”)