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.
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.
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.
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.
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.