Earning Less and Dying Younger: How the Growing Strain on America's Middle Class Is Pummeling Our Health
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This article originally appeared on Health Beat.
Last week, the Census Bureau came out with a report that provides a compelling window on poverty and health in America.
It's somewhat modestly titled "Income, Poverty, and Health Insurance Coverage in the United States: 2007." I would suggest it deserves a headline that does justice to its sweep, perhaps "Connecting the Dots: Health and Poverty, America's Shifting Priorities, 1960-2007."
Begin with this chart:
At first glance, what is most striking is how well President Lyndon B. Johnson's "War on Poverty" worked in the late 1960s. Seniors -- who were then the poorest group in the United States -- benefited most. The share of Americans over 65 scraping along somewhere below the poverty line plummeted from roughly 30 percent in 1965 to just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid legislation a priority, and when it passed Congress in 1965, it made an enormous difference.
The War on Poverty also helped kids: The share of the nation's children trapped in poor households fell from roughly 23 percent in 1965 to 15 percent during the Carter years.
By contrast, look at what has happened during the latest economic cycle. As the Economic Policy Institute's Jared Bernstein points out, "Despite strong overall economic growth, the cycle that began in 2000 and ended late last year has turned out to be "one of the weakest on record for working families."
Today, our children are our poorest citizens. Since President George W. Bush took office, the number of children living in poverty has climbed from 16 percent to 18 percent. In other words, a larger share of American children are poor today than in the early 1970s -- when the nation was mired in a deep recession.
"Overall" from 2000 to 2007, "the poverty rate grew from 11.3 percent to 12.5 percent," Bernstein notes. "In contrast, poverty rates fell significantly in the 1990s." The period from 2000 to 2007 marks a span when one would have expected prosperity to "trickle down."
Instead, the dollars shot straight upstream, like a school of salmon heading back to their breeding ground. Bernstein quotes income analysts Thomas Piketty and Emmanuel Saez [MS Excel], who show that "after falling with the stock market bust of 2001, the average income of the top 1 percent grew about 50 percent in real terms from 2002 to 2006, from roughly $850,000 to $1.3 million."
He adds: "Coming on top of the long-term trend in rising inequality since the late 1970s, this recent surge has resulted in the second-highest level of income concentration on record going back to 1913, as the richest 1 percent of households held 23 percent of income in 2006. The only year of greater income concentration was 1928 (24 percent)." (That, of course, marked the end of another era, the Roaring Twenties -- which would give way to the Great Depression.)
As for the middle class, from 2000 to 2007 median household income fell by more than $2,000 to $50,233.
What does all of this have to do with health?
The Uninsured, Medicaid and the Underinsured
The Census Bureau report attempts to put a happy face on U.S. health care by announcing that the percentage of Americans who are uninsured declined in the last year -- from 15.8 percent of the population to 15.3 percent. But as Jonathan Cohn points out over at the New Republic:
... before anybody gets the idea that we no longer need health care reform, take a closer look at the numbers. Enrollment in private insurance continued to decline in percentage terms, mostly because the percentage of people with employer-sponsored coverage fell from 59.7 to 59.3 percent. The reason the overall numbers look good is rising enrollment in public insurance programs, particularly Medicaid.
The fact that more people are eligible for Medicaid is not good news. This only confirms that the ranks of the poor are growing. (Over the past seven years, eligibility rules were not relaxed in most states; in many states they were tightened.)
Meanwhile, as the 21st century began, the number of Americans protected by employer-sponsored insurance slid while health care spending skyrocketed. In the 1990s, HMOs kept a lid on spending by saying "No" to many treatments. The trouble is, they denied coverage for effective as well as ineffective treatments. By the late 1990s, the backlash against managed care was so strong that insurers loosened their restrictions. As a result, from 1999 to 2005, the amount that insurers laid out for medical care rose by 8 percent to 8.5 percent a year.
They passed those compounding costs along, of course, in the form of higher premiums. Before long, many small employers found that they could no longer afford insurance; others shifted costs to employees in the form of higher co-pays and deductibles. Keep in mind that over the same span, the average worker watched his wages fall.
But the problem is not simply that 45.7 million Americans are uninsured. Recently, the Commonwealth Fund reported that from 2003 to 2007 the number of underinsured adults in the United States rose by 60 percent.
"Much of this growth comes from the ranks of the middle class," the fund explains. "While low-income people remain vulnerable, middle-income families have been hit hardest. For adults with incomes above 200 percent of the federal poverty level (about $40,000 per year for a family)," the share of underinsured has nearly tripled since 2003. As the fund defines it, someone is underinsured if they spent 10 percent or more of their income (or 5 percent if they were low-income) on out-of-pocket medical expenses, or if they had deductibles that equaled 5 percent or more of their income.
In other words, if you earn $50,000 and think you have insurance -- but you still have to pay $5,000 out-of-pocket on medical treatments that your policy doesn't cover -- you might think again. Does that piece of paper really deserve to be called "insurance"? Similarly, if you earn $40,000 and have a $3,500 deductible, you may well feel that you cannot afford to use your policy. You skip mammograms and Pap smears. You don't have your eyes checked. This is "insurance" in name only.
Yet with wages flat to down in recent years and premiums skyrocketing, more and more Americans cannot stretch their budgets far enough to afford full, comprehensive coverage. Still, they are luckier than families struggling to survive below the poverty threshold.
The Relationship Between Poverty and Life Expectancy
Life expectancy is one important measure of the health of a nation's citizens.
On this score, the graph below is shocking -- not because it shows that the United States spends far more on health care than other countries (see the right-hand axis) -- or that average life expectancy is lower (see how the light purple bars line up against the left-hand axis). We know this. What is startling is to see when it comes to life expectancy, only Cuba, Cyprus, Ireland and Portugal trail the United States.
Source: The Big Picture
When Barry Ritholtz posted this graph on his highly regarded financial Web log, The Big Picture, he observed that "this is the most embarrassing story never told. Even more embarrassing is that no one seems to care."
One reason many Americans shrug off charts like these is because they believe that the differences between say, Switzerland and the United States can be explained by the fact that our population is more "heterogeneous." In other words, they believe that African-Americans, Latinos and other minorities "drag down" our scores.
But as HealthBeat revealed, even if comparisons are limited to white Americans, we trail other OECD countries. Among Caucasians, when it comes to infant mortality we rank 22nd. If you look at the percentage of white mothers dying during childbirth, we place 19th. In terms of life expectancy, when compared to men in other developed countries, white men in the United States rank 22nd; white women, 19th.
How can this be?
One might assume that the fact that so many Americans are uninsured -- or underinsured -- explains our poor health. But it turns out that lack of access to medical care accounts for only 10 percent of premature deaths (see pie chart below).
Many would be quick to point to the fact that many Americans don't exercise enough and eat too much. And they would be right -- behavior is important. But there is one factor undermining the nation's health that we just don't like to talk about in polite society: Class. When it comes to health, class matters.
"Health is influenced by five (factors): genetics, social circumstances, environmental exposures, behavioral patterns and health care," explains Dr. Steven Schroeder, a professor at the University of California at San Francisco, where he directs the Smoking Cessation Leadership Center. "When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care -- which it does not -- only a small fraction of premature deaths could be prevented."
Schroeder offers the chart below to illustrate his point.
Where the patient lives -- social circumstances and environment -- explain 20 percent of premature deaths, while behaviors such as smoking account for another 40 percent. And those behaviors are, in turn, closely correlated to the patients' income and education.
Where a Patient Stands on the Socioeconomic Ladder Matters Most
Indeed, as a 2002 article in Health Affairs observes, according to the National Center for Health Statistics, "the most consistent predictor of the likelihood of death in any given year is level of education; persons ages 45-64 in the highest levels of education have death rates 2.5 times lower than those of persons in the lowest level. Poverty, another strong influence, has been estimated to account for 6 percent of U.S. mortality."
Income inequality takes a toll. A 1999 study in the British Medical Journal reveals that "each 1 percent rise in income inequality (the income differential between rich and poor) is associated with something on the order of a 4 percent increase in deaths among persons on the low end."
This begins to explain why the United States does so poorly in international health comparisons. For when it comes to income inequality, the gap between the wealthiest Americans and the poorest is much wider than in other nations.
Economic Inequality, Mental Illness and Behavior
The chart above, which was presented by Dr. Michael Wilks, president of the Standing Committee of European Doctors, at the World Health Care Congress last spring, suggests a correlation between the prevalence of mental illness (left axis) in a given country, and economic inequality (bottom axis). It turns out that the United States is an outlier in both categories.
When you compare the incomes of the wealthiest 20 percent to the bottom 20 percent in other developed countries, the ratio tends to fall somewhere between 5:1 and 6:1. In the United States, the ratio is roughly 9:1. In the United States, the poor are much poorer and the affluent are much richer. Meanwhile, more than 25 percent of Americans suffer from some form of mental illness, including depression.
What is the link between poverty and mental illness? "Studies have linked poor health to the constant stress of a lower-class existence -- a lack of control over one's life circumstances, increased social isolation, and the anxiety brought about by a subjective feeling of being of low social status (all of which can be compounded by racism)," Schroeder reported in a New England Journal of Medicine study titled " Class -- The Ignored Determinant of the Nation's Health."
"Physiologically," he explained, "stress appears to trigger a neuroendocrinologic response that is beneficial in the short term but over the long run can weaken the body's resistance to illness."
We know that depression and other forms of mental illness are strongly linked to poor physical health, as well as self-destructive behavior such as excessive drinking and smoking. At least 50 percent of the 2 million Americans with severe mental illness abuse illicit drugs or alcohol, compared to 15 percent of the general population, according to the Alcohol, Drug Abuse, and Mental Health Administration.
As for tobacco use, "The facts about smoking and mental illness are stark," says Schroeder. Almost half of all cigarettes sold in the United States (44 percent) are consumed by people suffering from some form of mental illness. This is both because so many people who are mentally ill smoke (50 percent to 80 percent, compared with less than 20 percent of the general population) and because they smoke so many cigarettes a day -- often three packs.
Where you live also influences health. When poverty is concentrated in certain neighborhoods, the air itself can be hazardous to your health, with neighborhoods like the Bronx reporting high rates of respiratory disease. In addition, these areas "are often dangerous and have high crime rates, with substandard housing, few or no decent medical services nearby, low-quality schools, little recreation and almost no stores selling wholesome food," Schroeder observes. This means that the residents, no matter what their race, income, or education, have little chance to improve their lives and engage in health-promoting behaviors."
Many blame the poor for being obese, arguing that they foolishly spend money on expensive high-calorie "junk food" when they could be preparing less expensive high-quality foods. But as professor Adam Drewnowski, director of the NIH Roadmap Center for Obesity Research, illustrates in the chart below, energy-dense foods cost less; nutrient-rich foods cost more. Quite simply, high-carb, high-fat foods are much more affordable than fresh fruit, vegetables, fish and other proteins. And they tend to be even more expensive in grocery stores in poor neighborhoods where pricey items turn over slowly and may spoil before they sell.
Source: Food Choices and Diet Costs: An Economic Analysis, Adam Drewnowski, Ph.D., director, NIH Roadmap Center for Obesity Research, professor of epidemiology and medicine, School of Public Health and Community Medicine, University of Washington
Meanwhile, finding a place to exercise in the ghetto can be difficult. "Gyms are too expensive for low-income families; exercising outdoors can be dangerous; and in inner cities, public schools often lack playgrounds and gymnasiums," Schroeder observes. Public school lunches in poor neighborhoods also tend to be made of ingredients that are cheap and high in fat, carbs and calories.
Until we are willing to raise taxes to pay for school lunches that include lean ground sirloin, fresh strawberries and smoothies made with fresh blueberries; safe outdoor playgrounds, school gymnasiums (and gym teachers), subsidized green markets and well-lit, well-policed jogging paths; perhaps we should stop blaming the poor for being overweight.
Poverty and Spending on Social Programs
As Wilks' chart above demonstrates, most other developed countries are largely middle-class. In the United States we accept much bigger gaps between the haves and the have-nots. The chart below shows, as a result, that a much larger percentage of U.S. children live below the poverty level. (Child poverty is defined as children living in households where income is less than 50 percent of household median income within each country. In the United States, median household income is $54,800; a child living in a household where joint income falls below $27,400 would be considered poor.)
This difference can be explained by the fact that in other developed countries, the affluent pay a significantly higher share of their income in taxes, and those revenues are used to create a social safety net.
The blue line in the chart above illustrates the correlation between expenditures and child poverty rates for all countries. Individually, the Nordic countries -- Sweden, Norway and Finland -- stand out, with child poverty rates between 2.8 percent and 4.2 percent. The United States is, once again, the outlier. We spend the smallest share of GDP on social programs and have the highest rate of childhood poverty -- five times as high as the Nordic countries.
Delivering the 117th Shattuck Lecture before the Massachusetts Medical Society last year, Schroeder connected the dots: "One reason the U.S. does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality and housing has unintended health consequences. Until we are willing to confront that reality, our performance on measures of health will suffer."
"It is arguable that the status quo is an accurate expression of the national political will -- a relentless search for better health among the (upper) middle and upper classes," Schroeder added. "This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health 'cures' and 'scares' are featured in the popular media. The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health -- whether judged on the basis of support for research, insurance coverage or government-sponsored public health activities -- is anemic."
This is in part because "the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties," Schroeder continued. "Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV-AIDS), and autism. These efforts are led by middle-class advocates whose lives have been touched by the disease. There have been a few successful public advocacy campaigns on issues of population health -- efforts to ban exposure to secondhand smoke or to curtail drunk driving -- but such efforts are relatively uncommon.
"Little is likely to change," Schroeder acknowledged, "unless low-income families have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care and reduce environmental threats. Social advocacy in the United States is also fragmented by our notions of race and class. To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates."
Indeed, both racism and "identity politics" have divided poor African-Americans and poor white Americans, blinding many to their common interests.
"The relatively limited role of government in the U.S. health care system is the second explanation," Schroeder argued. "The American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choice."
"Given that the political dynamics of the United States are unlikely to change soon and that the less fortunate will continue to have weak representation, are we consigned to a low-tier status when it comes to population health?" he asked
If we paid more attention to public health, and the poor, Schroeder concluded, we could "enhance the productivity of the workforce and boost the national economy, reduce health care expenditures, and most important, improve people's lives.
"But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for the population."
This does not mean that health care professionals can solve the problem. But they can lead the way in focusing attention on public health -- and the fact that poverty and poor health are blood relatives.