Good health may have less to do with our health-care system than you think

Should failure to finish high school be punishable by early death and by poor health for the dropouts’ children?

Who deserves a healthy heart more, the rich or the poor?

My opening questions are ridiculous and absurd, designed to be provocative in hopes you are will take some of the facts below as hard as I have.

  • Fact: On average, in America, college graduates live about five years longer than high school dropouts.
  • Fact: Rates of poor or fair health are about seven times higher among children in poor families than among children in affluent families.
  • Fact: In America, low-income adults are about 50 percent more likely to suffer from coronary heart disease, the leading cause of death in the United States, than are affluent adults.
  • Personal responsibility? Yes, maybe, to some extent, but tell it to infants who won’t reach their first birthday.
  • Fact: The rate of infant mortality (defined as death before the first birthday) for babies whose mothers did not graduate from college is almost twice the rate for children whose mothers graduated from college.

This post is not, at least not fundamentally, another one about the importance of expanding access to affordable health insurance. It is a prism held up to that debate to deflect attention for a nonce to another set of facts and ideas about health (not health care) in America.

Two weeks ago (and I’m embarrassed its taken me this long to write about it) I attended a fine but poorly attended and mostly un-covered presentation at the Humphrey Institute. The main speaker was Wilhelmine Miller, associate director of the Robert Wood Johnson Foundation Commission to Build a Healthier America. It was titled “Beyond Health Care.” Perhaps you can understand why it attracted only a couple of dozen and was ignored by the news media.

Even among the health-care obsessed, most of us are not ready to look “beyond health care” to look for other difficult ways to “build a healthier America.”

Furthermore, Miller was mostly presenting data from a 2008 report by the Healthier America Commission documenting the kind of health disparities by income, education and race that I sensationalized above, along with a follow-up report from April of this year in which the commission offered recommendation for reducing those disparities.

But as I watched Miller’s powerpoint presentation and its graphics illustrating those disparities of health by income, education and race, I was hit hard by this:

America’s horrible showing in all international comparisons of health outcomes (despite spending by far the most on health care of any nation) is not just about who has access to a doctor. Probably more than it is about the absurd shortcomings of the U.S. system of health insurance, those disparities are about class and, to a lesser degree, about race.

Take a look at the table just below. It shows how many more years an individual can expect to live, on average, beyond age 25, sorted by gender and family income.

More education, longer life
Robert Wood Johnson Foundation

The first — and shortest — bar in each gender group reflects the life expectancy of individuals in families with incomes below the federal poverty level. The fourth and tallest shows families with incomes at least four times the poverty level. The gap between the the tallest and shortest bars, on the men’s side, is eight years. Eight extra years of life for the affluent. Eight fewer for the poorest. Eight years. That’s a lot of years.

In 2009, for a family of four, a lowest bar would cover families with incomes at or below $22,050. The top bar therefore covers families at $88,200 and up.

Please note that while the figure shows a huge gap between top and bottom, the overall graphic shows not just a disparity between the richest and the poorest but a steady increase in life expectancy at each step. The poorest families qualify for Medicaid, whereas the middle two bars include many families that do not qualify. In class terms, the “working poor” families — too rich for Medicaid but holding crummy jobs with little or no health benefits — are the group mostly likely to be living without health insurance.

That’s another short-cut to the argument that poor health outcomes are not just, and maybe not primarily, about access to healthy care. Of course it is better, speaking health-wise, to have insurance than not. I hope that our Congress and our country will soon complete the short-term legislative task of removing various barriers to health access, whether caused by unaffordability or by pre-existing conditions or some other cause. But this graphic and those to follow make a strong argument that simply being poor is bad for your health, even if you have access to health care. I suspect it also means that the United States will continue to look bad in international health comparisons, even if more people have health insurance, because our country has more poverty.

If you can stand this stuff, the full report (pdf) slices and dices the comparative health data many ways, including by education level and race and many combinations thereof. The graphs in this post are just a selection. Below is the infant mortality rate for children born to mothers who reached various levels of education.

A mom's education, a baby's chance of survival
Robert Wood Johnson Foundation

Education and income are obviously highly correlated. I include this one because for the benefit of those whose thinking on issues like these runs strongly toward the idea of personal responsibility. America is a land of opportunity. Education, at least through high school, is free. If you stay in school, don’t join a gang, stay off drugs, get a job and have a good work ethic, you do not have to be poor. So to what degree should the relatively affluent taxpayer have to pay for the poor life choices made by a stranger? It’s a complex discussion.

It is certainly easier for some young people to get on and stay on the path to the middle-class American dream than others. In the context of the larger liberal-conservative argument over what the government should do, this is important. But it is also complicated by issues such as those illustrated by the graphic above, which I sensationalized in my opening. A significant factor influencing the odds that a newborn child will survive to its first birthday is whether its mother has a high-school diploma. Without being cavalier about the challenges facing a particular young woman versus another, the mother has some control over whether she stays in high school. The baby has none.

The Robert Wood Johnson commission also found that if you ignore income and education but focus on race, there are significant disparities. Among black adults, 20.8 percent report that their health is poor or only fair. Among whites, just 11.4 percent say that. Hispanics are in between with 19.2 percent.

So race matters. Members of minority races are also more likely to have low incomes. But if you sort by both income and race, it’s pretty clear that class is much bigger than race as a predictor of health. In other words, poor blacks are still more likely to report poor health than poor whites, and the same for higher income groups. But income still appears to be the more powerful factor of the two, as illustrated by the figure below.

Racial or ethnic differences in health regardless of income
Robert Wood Johnson Foundation

Blacks and hispanics with poverty-level incomes are much more likely to be in ill health than members of the same racial groups who have higher incomes. The gaps by class are bigger than the gaps by race. The RWJ commission went out of its way to make this point, perhaps because differences by race, that may be purely genetic, are more difficult to overcome, or perhaps because the politics of race are deep-seated.

But poverty and poor health — even unto early death — tend to run together. This is probably true for all countries but is especially costly to health outcomes in our country because we have so much more poverty. Take, for example, this graphic displaying the rate of child poverty in the 25 member nations of the Organization for Economic Cooperation and Development, basically a club of the wealthy nations of the Western world, plus a couple of other nations that we don’t usually think of wealthy or western.

More child poverty in America
Robert Wood Johnson Foundation

As you can see, in this data from the second half of the 1990s, the United States ranks 24th out of 25. In Denmark, which has the lowest rate, 2.4 percent of children live poverty. In the United States: 21.7 percent. This is really a national disgrace, for such a wealthy nation as ours.

So, after amassing and analyzing all of this data in 2008, the Commission to Build a Healthier America published in 2009 a second study, titled “Beyond Health Care,” which I take to mean that we need to move beyond just trying to get more Americans insured and get them into the health care system. The commissioners compiled a list of 10 recommendations toward a healthier America that don’t have much to do with doctors and hospitals but are targeted more on reducing the deficits that cause poor people to be less healthy. The recommendations focus on things like diet, exercise, smoking cessation, healthy housing and on developmental education for small children.

We’re talking about things like feeding healthier meals to kids when they are in school, requiring that every kid get some exercise every day during school.

Here’s another example that wouldn’t occur to middle-class folks who have easy access to plenty of good and healthy groceries. From the report:

“Many inner city and rural families have no access to healthful foods: for example, Detroit, a city of 139 square miles, has just five grocery stores. Maintaining a nutritious diet is impossible if healthy foods are not available, and it is not realistic to expect food retailers to address the problem without community support and investment. Communities should act now to assess needs to improve access to healthy foods and develop action plans to address deficiencies identified in their assessments.”

That leads to this recommendation: “Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods.”

When most of us think about improving health in America, we probably don’t start thinking about the shortage of grocery stories in Detroit.

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Comments (18)

  1. Submitted by Justin Heideman on 10/12/2009 - 10:33 am.

    It is more than just access to grocery stores. It’s also what those stores sell. We subsidize the bejezus out of corn and soybeans, which are used to make highly processed and unhealthy foods. It’s kind of crazy when you think about it: The cheapest stuff in the stores, the most unhealthy, is the stuff that has the most processing and energy spent on it.

    Until we drop the subsidies for corn and soy, we’re not going to get any real change on the front of healthy food.

    It also gets really interesting if you drop the subsidies on corn, because then meat becomes more expensive. And the production of meat for human consumption is hugely inefficient, and a large contributor to greenhouse gasses.

  2. Submitted by Tim Nelson on 10/12/2009 - 10:58 am.

    I agree with the title of this article.

  3. Submitted by Thomas Swift on 10/12/2009 - 11:45 am.

    “Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods.”

    Freddie-Mart and Fannie-Saver; a CRA for the grocery industry.

    Because GSE’s and socio-economic reform via government regulation have such a kick-ass record of success we’d be crazy *not* to apply them to every facet of our lives…right?

    OK, I already feel a tremendous head-ache coming on and it’s still early, so let’s move on.

    The stat’s for education are self evident.

    People that enter adult life without even a high school education are doomed to live lives of struggling and failure…a-yup, that’s pretty much what I’ve been saying for ten years.

    So Eric, are you going to defend the record of public education in the urban areas most affected by poverty?

    If education is such a reliable predictor of poverty and early death…why haven’t we done something about it?

    Saint Paul school district fails 42% of it’s senior-aged students….42% every year for the past 10 years. Through periods of increased funding…42% fail….periods of less funding…42% fail. 10 years….42% fail.

    What gives?

    The only thing more consistent than failure is the people holding the reigns of power:

    Liberals and the teachers union. Go ahead, Eric, please explain to us how that isn’t a fact.

    Until someone from the left is willing to admit that the influence of the left wing socio-political agenda and union control are a large part of the problem with public education, I’ll continue to reject pieces such as this for the smarmy, self-serving pap it is.

    Meantime, I’ll keep an eye out for Satan riding a snow mobile.

  4. Submitted by Richard Schulze on 10/12/2009 - 12:31 pm.

    Great article. Personal responsibility and being educated about what you put into your body and how it effects your health should be the responsibility of every individual and parent. Sadly it has not proven to be the case.

    Swiftee: Regarding CRA, Freddie and Fannie MAE. Once again you use anecdotes as your platform instead of facts and figures and it reflects in the errors of your conclusions.

    Regarding CRA which Mr. Swift uses as a red herring to shoulder blame for the financial collapse of America.

    The CRA has nothing to do with the financial crisis. How do we know this?

    1) It has been in place for some thirty years, so if its going to produce disasters its not a very good explanation of a current crisis.

    2) 80% of non-prime loans were made by non-regulated entities not subject to the CRA. So obviously their behavior was not in any way prompted by the CRA.

    3) The institutions that were regulated and were subject to the CRA, none of them had any CRA rating problems. So they weren’t making these loans to try and improve their ratings. They already had great ratings.

    4), What changed in CRA regulation over the recent period relevant to the crisis? It was weakened and not strengthened as a result of Phil Gramm in the senate and Jim Leach in the congress and the repealing of the Glass-Steagall Act in 1999. The bills were passed by a Republican majority, basically following party lines by a 54-44 vote in the Senate and by a bi-partisan 343-86 vote in the House. The banking industry had been seeking the repeal of Glass-Steagall since at least the 1980s The great success of the Glass-Steagall act was that it separated depositors from risky bets. Depository institutions will now operate in “deregulated” financial markets in which distinctions between loans, securities, and deposits are not well drawn.

    I can assure you that all this CRA hooey is all made up.

    Fannie & Freddie do have a role to play in this crisis. But it’s not the one that most people think about. Fannie & Freddie ironically were the primary reasons we didn’t have a crisis in sub-prime much earlier. Because Fannie & Freddie only purchased prime mortgages for packaging. And Fannie & Freddie’s standards in general are very good, that’s a conforming mortgage in jargon and so in the old days the non-prime folks could not sell their stuff because only Fannie & Freddie could by it.

    What changed? We passed a law that allowed what we call Private label to create mortgage-backed securities. So these are primarily investment banks. It’s the investment banks that purchased the non-prime loans. Then sent them to the rating agencies to receive bogus AAA ratings.

    So it’s overwhelmingly again a story of actually a weakening and the creation of competitors to Fannie & Freddie that led to this. But Fannie & Freddie did NOT purchase sub-prime loans, but exotic derivatives, the ones that got the phony AAA rating from the rating agencies. Primarily liar loans and it did so while at a time when the Office of Federal Housing Enterprise Oversight was regulating it and had full regulatory power to stop this practice. A conservative republican ran OFHEO, he did not stop this practice, and he did not think it was risky. It is also true that the Bush administration pushed the stuff, remember the “ownership society” it was in fact a “bipartisan effort”. Fannie & Freddie are massively insolvent as a result of the CDO’s they purchased.

    Conservatives have miscast history to such a degree that it is almost as if “conservatives” were not in complete control of government from 2001 through 2007 when many of these issues were born.

    If you were employed in the banking, mortgage or securities industry you would already know this to be true. Just because you have a savings account does not make you qualified on the subject of economics and or financial securities. Your comments regarding CRA are nothing but “Tom Foolery”

    It is always a big mistake to theorize before one has data. Because one begins to twist facts to suit theories. Instead of theories to suit facts.

  5. Submitted by Peter Soulen on 10/12/2009 - 12:34 pm.

    Eric, I think it was George Bernard Shaw who said: “no question is so difficult as one to which the answer is obvious”

    I spend time at the Strib site too, reading the articles and the reader comments about them. I’m shocked at the number of commenters who really and truly appear to care for no one and nothing but themselves. Maybe it’s a function of that site’s user anonymity, but I see that attitude in more places than that – where people place comments that display an ugliness of soul that is quite chilling – using their own names.

    It reminds me of what I noticed so often in the Sarah Palin of the ’08 campaign… Somewhat ignorant and proudly so! It’s so saddening to see that there are so many folks out there who are just plain mean – and proud of it.

  6. Submitted by Howard Miller on 10/12/2009 - 12:49 pm.

    Mr. Swift’s conclusion that liberals and teacher unions are to blame for poor health and poverty due to their hand in public education is just the sort of reality-free associational thinking we could use less of in the United States.

    Our great advances as a society are tied to our expansions of educational access to k-12 and higher ed. If conservatives ran things all the time, there’d be no public education at all;

  7. Submitted by matt chapman on 10/12/2009 - 01:59 pm.

    Eric, about half way through the article you mention a critical phrase, ‘personal responsibility’. I would be very interested to see a behavioral psychologist come up with a survey to measure personal responsibility. Then it would be interesting to see how/if a measure of personal responsibility correlates to any of these (income, education, health metrics).

  8. Submitted by Rebecca Hoover on 10/12/2009 - 02:00 pm.

    Thanks for this article. It certainly is apparent to me as I spend time in the world that many of our less educated friends do not really understand what a healthy diet is and how to have a first class diet on a recession budget. The shunned foods of brown rice and beans are often exactly what most folks need.

    Also, I read the Wood Foundation report and, of course, it did not get quite as specific as needed to see exactly where some of our problems arise.

    I wish as part of health care reform, we would address the lack of health education that is severely impacting the health of those with less education. This is true especially since life style choices lead to increased rates of cancer, diabetes, heart disease, etc.

    For an idea of how crucial food and other life style choices can be, consider the following. About 50 years ago, a professor of neurology from Oregon started experimenting with diet and life style improvements to treat multiple sclerosis and eventually he conducted that disability could be avoided by about 95% of multiple sclerosis patients who merely adopted a healthy diet and a few other sensible measures. He was quite precise about what he meant by healthy diet, and information on his diet is available on a web site still run by the Swank Foundation. Professor Swank diet only last year and has had a major impact on the treatment of MS in some areas in the world.

    More currently, another professor of medicine from Australia has also started writing extensively about the importance of life style changes in the treatment of MS and he also believes most of those with MS can avoid disability by eating right and making other sensible changes. His name is Dr. George Jelinek and his web site is .

    Thanks again for this article. It has some good food for thought and gives me the inspiration to soldier on in some work I want to do in this area.

  9. Submitted by Glenn Mesaros on 10/12/2009 - 02:23 pm.

    Here is what Robert Wood Johnson Foundation is advocating.

    How a handful of progressive foundations and quasi-government agencies
    set out to provide equitable distribution of health care,
    and in the process, created a duty to die and a culture of death.
    And how they hope to secure their legacy . . .

    Featuring the collaboration of:
    the Hastings Center, the Robert Wood Johnson Foundation (RWJF),
    George Soros’s Project on Death in America (PDIA), Institute of Medicine (IOM),
    AARP, Choice in Dying, and a number of prestigious universities,
    to name only a few.

  10. Submitted by Ray Marshall on 10/12/2009 - 05:47 pm.

    Comparing the U.S. with the 24 other OECD countries is not a valid sample.

    Denmark, for example, has a population slightly larger than that of Minnesota but with a homogeneity far greater.

    Immigrants to Denmark over the past 50 years would be miniscule compared to those in the United States.

    And, this would be an interesting “homogeneity index” to calculate; Denmark has a list of approved names that parents might choose for their children. I don’t believe names like “ESPN” would be approved by the state names registry.

    European countries also have Police registries that require residents to register with the police department when they move to a new home.

    I’m sure there are lots of other factors in most countries that do not allow the freedom that we have in this country. With that freedom comes the ability to engage in self destructive behavior.

  11. Submitted by Bernice Vetsch on 10/12/2009 - 05:58 pm.

    Re: the number of children living in poverty in various countries.

    The U.S. is the only country listed that does not assure every citizen the same regular access to health care as everyone else, poor or not. Many of them have tax-supported public systems; some have private insurance systems but — like Norway and Switzerland — the companies must be non-profit and must conform to government-mandated premium prices, benefit sets and formularies, and may not refuse coverage or refuse to honor any claim. Purchasing insurance is mandated, but the government helps the poor pay their premiums.

    In those countries, competition is on the basis of customer service. Insurance companies make their livings from this work, but not (literal) killings in their pursuit of profit.

    This system could be the compromise that works, one that DOES provide care to all, and which would stop the yearly rise in premiums coupled with reductions in the “losses” represented by paying instead of denying claims.

  12. Submitted by Beryl John-Knudson on 10/13/2009 - 07:40 am.

    “The times they are a changing”…?

    John Kozol’s book “Savage Inequalities” was published in 1991. The conditions described, reflect that time period. But pulling the book out again this morning (surprised I found it so quickly in our library of some 11,000 books) and doing a quick scan of the chapters…stories reflected ‘then, pretty much reflect ‘now’.

    Kozol’s book – one of many on the subject – could easily bear the publishing date, 2009. Nothing appears to have changed that much; twenty years later?

    Someone earlier commented here on the concerns we show only for ‘me’ and mine’; or a similar indictment. Will we ever respectfully put ourselves at the end of the line for once…in a world where first-in-line, first served, is the only dogma we respect?

    I suppose, in a nation which too often applauds and patriotically defends a more fractured view of democracy, it’s difficult to honor that which is intrinsically woven into the original fabric of this good nation…the concept of justice and equality?

  13. Submitted by Brent Lorentz on 10/13/2009 - 07:57 am.

    I think the premise of this article is flawed. It assumes causation based on correlation. Simply stated, to claim that “being poor” causes “bad health” is purely speculative and ignores equally likely possibilities such as “bad health” causes “being poor,” or that “bad health” and “being poor” are both results of an entirely different cause (for example poster # 7’s “personal responsibility” metric).

  14. Submitted by John E Iacono on 10/13/2009 - 12:41 pm.

    Excellent piece of research and commentary, as usual.

    I am most struck by the discrepancy emerging from the different levels of education.

    While this would seem to endorse Mr. Swift’s position about our failing schools, in fact (while not discounting the public school problems he refers to) the causes are in my opinion much more complex.

    >It seems to me that a stable home has much to do with a child’s success — and subsequent longer stay — in school.

    >It seems to me that welfare policies that allow a girl with teen pregnancy to “emancipate” herself by having a baby contribute to the early exodus from school, as caring for a child is much more than a teen is prepared for.

    >It seems to me that the influence of failed older youth selling drugs on the streets unmolested helps young men to think education is not needed to succeed.

    >It seems to me that our society’s current casual attitude toward marriage and especially divorce — which almost guarantees a woman with children a place amongst the chronically poor — has a role to play in this situation.

    >Add to this a focus on “me and my emotional needs” with little regard for the childrens’ welfare, and the problem is exacerbated.

    >It seem to me that societal (and school) attitudes toward casual sex and cohabitation contribute to the problem.

    >It seems to me that minimum wage standards so low that those earning it can still fall within official poverty guidelines do not help.

    >It seems to me that band-aid solutions like opening subsidized grocery stores without tightening what food stamps can be used for are simply whistling in the dark.

    >It seems to me that a long term approach to this discrepancy should approach more of the causes of the problem I have listed, and many others I have not mentioned, if we hope to reduce this problem.

  15. Submitted by Bernice Vetsch on 10/13/2009 - 05:05 pm.

    Mr. Mesaros — Sounds like you are describing the non-existent “death panels” the right wing was scaring people with in August.

    None of the persons or groups you mentioned would be advocating dying off. They are talking about people making their own end-of-life-decisions and letting their families and doctors know what they want before the time comes when they are too sick to do so.

  16. Submitted by John E Iacono on 10/14/2009 - 12:08 pm.

    I suspect Glen and Bernice have little to fear on the matter of death panels.

    Early twentieth centry eugenics has pretty much fallen out of favor since the discovery of Hitler’s death camps showed to what it could lead.

    Only a few radical groups still support the idea, and they are usually careful to shield their views from the public eye.

    It does pop up now and then in discussions about egg fertilization and abortion, but that’s about all.

    But any politician who voted for one, or did not vote to abolish one that happened to be set up, would find it a much hotter potato that s/he ever imagined.

  17. Submitted by tim johnson on 10/17/2009 - 11:59 am.

    Pretty good piece, but Mr. Black falls too often into mixing correlation with cause.
    Lacking a high school education doesn’t cause, or isn’t an “influencing factor” in early infant mishealth, necessarily.
    It’s more of a “predictor,” a term Black uses later, but appears to confuse with being an influencing factor.
    It’s probably closer to the truth to say, generally, that people who fail to finish high school tend to be people who don’t take care of their own health as well as they could or should, nor that of their children.
    Lacking a high school degree doesn’t “cause” ill health.
    It’s sort of like the dumb “stats” used in ads against second hand smoke alleging that people who work in bars get lung cancer at 50 percent higher rates than people who don’t… well, come on; people who work in bars tend to smoke at a rate at least 50 percent more than people who don’t work in bars, also tend to drink more and otherwise lead lifestyles less healthy than people who don’t work in bars, which no doubt is why their cancer rates are higher, more so than because of second-hand smoke.
    That’s not to ignore the general truth that life is better the more money you have. It’s good to be the king.
    Another key fact that Black really should have included is that the disparate data on infant mortality in America compared to other nations is due largely to the fact that far more “preemie” work is done in the United States than most nations and the mortality rate of very premature babies is included in the overall infant mortality rates, a fact that isn’t the case in many nations. So it skews the data.

  18. Submitted by John E Iacono on 10/19/2009 - 10:06 am.


    Very thoughtful and relevant post.

    It’s true that lack of high school education may not “cause” of early infant ill health, and may be a predictor only, as in the case of second hand smoke.

    But it’s also true that it may be a contributing factor, and therefore at least a partial “cause” of this condition, insofar as lack of basic health information which would be learned in high school would have the effect of reducing the mother’s ability to care for the child properly.

    And I am sure EB is aware of the disparate methods of counting infant mortality (US counts those who die in the first 24 hours; others do not), and perhaps should have mentioned whether this statistic included them. In fairness, however, it should be pointed out he was not comparing us to others here: only referring to the rates of death before reaching the first year in our country.

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