The United States is known for having one of the most expensive and worst health care systems in the world.17.2% of our GDP is directed to health expenditures, compared to only 9.7% in the U.K, 10.9% in Japan, and 11.3% in Germany. Not only do we spend outrageously more than any other country, we don’t have a better system to show for it. Our death rate per 100,000 children aged 1-19 is 259 compared to 170 in the U.K, 147 in Japan and 166 in Germany. Even though we are one of the richest countries in the world, our people have one of the shortest life expectancies of any industrialized nation. Why in the world do we still have millions of Americans that don’t have access to basic preventative services and why do we pay so much?
The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health related societies to ladders. In this relationship, the rungs of the ladder are equivalent to the resources available for individuals in that “step” to live a healthy, secure, and prosperous life. This means that the individuals at the top of the ladder are the ones who possess college degrees, respected careers, and are financially prosperous. The individuals at the bottom of the ladder are not as privileged. They aren’t as educated, have lower income or unstable employment, and aren’t financially comfortable. Socioeconomic status contributes to disparities in health in that an individual’s place on the ladder directly affects how healthy they are or will be in their lifetime. For example, the risk of dying prematurely is 3 times greater for low socioeconomic individuals who fall on the lower rungs of the social ladder. When considering people in the middle, they are still 2 times as likely to die prematurely than the individuals at the top of the ladder. In addition to life expectancy, individuals at the bottom of the ladder are more likely to suffer from hypertension, obesity, diabetes, heart disease, HIV/AIDS, mental illness, and experience newborn health complications such as low birth weight, premature birth and birth defects.
The power that social status has over health and the quality of life we live is colossal and pervasive.
Individual Behavior vs. Genetics
There is a reason providers review family history with patients: genetics plays a role in the health of an individual, but behavior also largely contributes to health status. This doesn’t necessarily mean that the responsibility of health falls on the individual at 100%. The lower they are on the social ladder, the harder it is for them to practice healthy behaviors. An individual’s environment has the ability to expand or constrain the options and habits that improve health and prevent chronic diseases. For example, lower socioeconomic communities have fewer (or sometimes lack) fresh produce supermarkets, recreational facilities, libraries, and safety but have more liquor stores, fast food restaurants, and drug trafficking. to accompany this environment, stress levels are high in individuals who live in such communities. Stress directly impacts physical health, but also leads to individuals partaking in destructive behaviors such as smoking, abusing alcohol and consuming high levels of sugar and fat.
Clearly, the relationship between behavior and the ladder isn’t as easy as scaling will-power. The issue with our medical model today is that many physicians look at patients and their diseases through only the biomedical model of health. Social and psychological factors are rarely accounted for. Appointment slots are 15-minutes for most practices and providers who feel compelled to do more simply don’t have the time. We can’t look at an obese patient and think “they have no moral fortitude and are lazy!” Alternately, we need to consider the patient’s position on the ladder to better understand their behaviors and properly formulate a treatment plan. Individuals on the bottom rungs of the ladder face environmental and social conditions that induce unhealthy behaviors. They are exposed heavier cigarette and alcohol marketing, they live with chronic high levels of stress, don’t have the same access to healthy food options due to location and price and have fewer educational and job opportunities. Motivational interviewing is new technique recommended for providers to help their patients practice healthier behaviors, but that discussion will have to be for another day.
Minorities and Health
The inequalities in health status shared among minorities in the United States is shocking. Not only are minorities more likely to be at the bottom of the social ladder, they have a much higher risk of developing various diseases compared to non-minorities in the same position on the ladder. Racial health disparities are due (mostly) to an unjust distribution of socioeconomic resources and not genetics. Minorities are more likely to live at or below 200% of the Federal Poverty Line, be less educated, and live in low socioeconomic communities. These are a few of many social factors that determine the health of an individual. Instead of being considered separate entities, they are a reflection of one another. Low education leads to low paying jobs. Low paying jobs leads to living in low-income communities. Low-income communities lack social resources (recreational facilities, libraries, fresh produce supermarkets) and have high crime rates. This environment influences health damaging behaviors like smoking, drinking alcohol, and abusing recreational drugs. Although Medicaid is available to low-income individuals, people who have a job and make more than the limit, don’t qualify for Medicaid but also can’t afford private insurance. This lands them in the insurance gap position, with little to no access to preventative services. This means they seek health care services when they are very ill or in life threatening situations.
In 2016, 40% of people living in the United States were people of color. By 2050, that number is projected to increase to over half of the population. Given that people of color make a disproportionate share of the low-income and the uninsured relative to their size in the population, addressing health care disparities is extremely important. Disparities not only affect the groups directly suffering, but also hinders improvement in the quality of care and health for the broader population and leads to unnecessary costs.
Why Address Inequality in Health and How to Do It
Not only are we improving individual health, we are decreasing health care expenditures because healthy people require less medical services. Pinpointing the underlying determinants of disease and successfully addressing it is the first step in reducing health care expenditures. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health identified two policies that are required to reduce premature death and eliminate the increase in disparities as you move down the social ladder:
- Policies that affect the length of the ladder and the distance between it’s rungs.
- Policies that buffer the damaging conditions of living below the top rungs.
Changing the Ladder
To alter the length of the social ladder in the United States, we need to advocate for policies that improve access to quality education and impact income distribution. There is no reason for a qualified student to not attend college in the United States of America because of financial barriers. Also, public education should be of high and equivalent quality throughout all K-12 levels. In terms of income and wealth distribution, we need policies that increase saving incentives in family households and offer opportunities for job training and community colleges to lower socioeconomic individuals.
To ameliorate the risks linked to an individual’s socioeconomic status, we need policies that improve the environment and limit bad behaviors. Such policies should reduce violence and crime, increase affordable housing, improve access to drug and alcohol abuse programs as well as smoking cessation programs, increase taxes on cigarettes, fast food and alcohol, make school lunches more nutritional, and support green markets and fresh produce grocery stores. These are some examples of many policies that would improve the quality of life that individuals on the bottom of the ladder live.
What You Can Do to Help
You don’t have to start a non-profit or get into politics. Although those are great things to do, you can help in many other ways. Here are five things you can do right now, regardless of your financial situation, to help bring health care access to people in your community.
- Become a mentor to a minority student at your local high school. Help them find their passion and motivate them to pursue a higher education. Educate them on requirements to get into college and how to finance the costs.
- Create a book drive to provide a mini public library to a neighborhood in your area that doesn’t have one. Books can be donated to the local school or could be handed out to students at an event.
- Volunteer your skills. If you are a nutritionist or maybe a personal trainer, consider offering free services on the weekend to people in your community who need it most. Educate them on how to make better food choices and teach them exercises they can do at home.
- Donate to smoking cessation or alcohol abuse programs in your community.
- Help a neighbor plant a garden. Motivate your peers to eat healthier and make better health choices.
Remember: a little goes a long way. Just because you don’t see the results of your efforts immediately, doesn’t mean you aren’t making a difference! Keep pushing towards a better future for our generation and the next.
Orgera, K., Artiga, S. (2018). Disparities in Health and Health Care: Five Key Questions and Answers. 2020 Kaiser Family Foundation.
Adler, N., Stewart, J. (2010). Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.
Fiscella, K., Williams, D. (2004). Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Academic Medicine, Vol 79, No. 12.
Pampel, F., Krueger, P., Denny, J. (2010). Socioeconomic Disparities in Health Behaviors. National Institute of Health Annual Review Social, 36: 349-370, doi: 10.1146.
Cohen, S., Janicki-Deverts, D., Chen, E., Matthews, K. (2010). Childhood Socioeconomic Status and Adult Health. Annals of the New York Academy of Sciences: The Biology of Disadvantage, doi: 10.1111.