Health and mortality inequalities in the US

How unequal are we when it comes to inequalities of health and mortality? Richard Florida (CreativeClass) points to an important new study on this question by public health researchers at Harvard and UCSF. (This is one of many items that Florida references in his Twitter feed -- it's certainly worth following. This bears out the academic value of Twitter!) The study is "Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States". And the answer the researchers provide to the question above is -- very. The study is worth reading in detail.

The authors analyze mortality statistics by county, and they break the data down by incorporating racial and demographic characteristics. The data groups fairly well around the eight Americas mentioned in the title:


Here is how they describe their findings:

The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.

And here is their conclusion:

Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

For example, their data show that "the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001." This is an enormous difference in longevity for the two groups; and it is a difference that tags fundamental social structures that influence health and risk across these two populations.

Here is a time-series graph of the behavior of longevity for the eight Americas:
So what are the factors that appear to create these extreme differences in mortality across socioeconomic and racial groups in America? They consider health care access and utilization; homicide; accidents; and HIV as primary potential causes of variations in mortality for a group. Most important of all of these factors for the large populations appear to be the health disparities that derive from access and utilization. And here they offer an important set of recommendations:

Opportunities and interventions to reduce health inequalities include (1) reducing socioeconomic inequalities, which are the distal causes of health inequalities, (2) increasing financial access to health care by decreasing the number of Americans without health plan coverage, (3) removing physical, behavioral, and cultural barriers to health care, (4) reducing disparities in the quality of care, (5) designing public health strategies and interventions to reduce health risks at the level of communities (e.g., changes in urban/neighborhood design to facilitate physical activity and reduce obesity), and (6) designing public health strategies to reduce health risks that target individuals or population subgroups that are not necessarily in the same community (e.g., tobacco taxation or pharmacological interventions for blood pressure and cholesterol).

These findings are squarely relevant to the healthcare debate currently underway in the United States. The country needs to recognize the severity of the "health/mortality justice" issue, and we need to reform our healthcare system so that these disparities begin to lessen.

Paying for health

A person's income determines his/her access to many things he wants and needs: food, clothing, transportation, housing, entertainment, and the internet, for example. And people who have higher income are able to consume more of all of these categories than people with lower income, if they choose to. More affluent people shop for food at Papa Joe's or Whole Food; live in larger and more luxurious homes; buy their clothing from boutiques rather than Penny's or the thrift shop; and drive multiple handsome cars. Poor people can't afford the luxury end of these forms of consumption. And in some way our culture has judged that these sorts of inequalities of consumption are a legitimate and fair part of a market economy; if you judge that inequalities of income are justifiable (perhaps with some limits on extremes), then you pretty much have to support the idea of inequalities of consumption as well.

But what about goods that have a price but that are essential to living a decent human life? Food certainly falls in this category; if 30% of society could literally not afford to purchase enough calories to provide 2200-2900 calories per day for adults and 1800 calories for children, then we would probably have a different idea about the fairness of a market for food -- the principle that says "to each according to his/her earning capacity" doesn't seem very convincing in circumstances where it leads to malnutrition or starvation. In other words, if the normal workings of a market economy left a significant segment of the population without the ability to purchase enough food for subsistence, we would surely judge that this isn't a fair or socially just way of distributing income and food. And there is an important point to be noted here: there is hunger in America, and the system of producing goods and income isn't fully satisfying the subsistence needs of the whole population. (This is exactly what makes it compelling that our government needs to provide food assistance for the very poor, through food stamps or targeted income supplements.) So there is an important issue about the justice of current actual distributions of such basic goods as food, clothing, or shelter across the U.S. population.

But push a little deeper and consider the "market for health care". Supporting one's current healthy status is a costly effort; repairing the body in times of traumatic injury or serious illness is even more costly; and our society leaves a lot of the allocation of health care services to private purchasing power. Health insurance is the primary vehicle through which many Americans provide financially for their health care needs. Some people have insurance provided or subsidized through their employers; some families purchase health insurance through the private market; and many families lack health insurance entirely. Upwards on 45 million Americans are uninsured, including 20% of adults and 9% of children (CDC link). And this includes a wide range of Americans, from the extremely poor to the working poor to the solidly middle class.

It is clear that access to doctors, hospitals, nurses, and prescription drugs is a critical need that everyone faces at various points in life. It is obvious as well that one's future ability to live and work productively and to enjoy a satisfying life is conditioned by one's ability to gain access to health care when it is needed. It is also clear that uncertainty about the availability of health care is a major source of anxiety for many, many people in U.S. society today. So it is self-evident that decent health care is one of our most basic and unavoidable needs.

So what do people do when they lack health insurance and serious illness or injury occurs? This isn't a mystery anymore; families go into debt to doctors and hospitals, they face bankruptcy, they find some limited sources of free care (free clinics, pro bono doctors' services), and they forego "optional" treatments that may well extend the length or quality of life. And it is evident that this pattern results in very serious harms and limitations for people in these groups. People who have the least access to health care through our basic institutions may be expected to live shorter lives and to suffer more.

And what about people at the high end of the income spectrum? How do they relate to the problems of health? Here too the answers are fairly well known: they are able to seek out the best (and most expensive) specialists, travel to national centers for specialized treatment, and undergo advanced diagnostic tests that are not covered by insurance. (Here is a news story from CNN on boutique health care.) The affluent aren't able to assure their health through expenditure -- but they can certainly improve their odds.

In other words, ability to pay influences the quality and extent of health care that an individual or family is able to gain access to; and the health status of the family is affected by these variations in quality and access. So, to some meaningful extent, our social system places health care in the category of a market good.

But here is the question I'm working around to: what does justice require when it comes to health care? Is it right to look at health care as just another consumption good like shoes -- affluent people wear Gucci and poor people wear Dollar Store, but everyone has his/her feet covered? Or is health care in a special category, too closely linked to living a full human life to allow it to be distributed so unequally?

It seems a bitter but unavoidable truth that there are very substantial inequalities in the provision of health care in our society. One person's likelihood of surviving a devastating cancer may be significantly less than another person's chances, simply based on the second person's ability to pay for premium health care services. Further, it seems unavoidable that these inequalities are flatly unjust in any society that believes in the equal worth of all human beings. And where this seems to lead is to the conclusion that some system of universal health insurance is a fundamental requirement of justice.

Is there a right to healthcare?

It is worth unpacking, first, why healthcare is so crucial to everyone's life. Everyone faces illness and accident in life. Maintaining and restoring health and function are crucial to our quality of life and our ability to live fully, freely, and independently. So access to healthcare is one of those core needs that are so closely connected to a good human life that they can be regarded as an essential human good (for example, nutrition, education, and freedom). A life deprived of access to decent healthcare is likely to be one of unnecessary pain, anxiety, and limitation.

The medical resources that are available today for addressing the challenges of illness and disability are incredibly powerful, compared to the first half of the twentieth century. But they are also very expensive -- socially and privately. Insurance is a way of spreading out these costs over a population of people with varying levels of risk; each contributes part of the cost of this risk-sharing system, and each is assured of help when the occasion arises. And people lacking health insurance are faced with cruel choices: do without the effective therapies that exist for their illnesses; or do without other crucial things like food, gas for their cars, or paying their rent.

This gives us reason to judge that healthcare is not simply another consumable resource which people have more or less of; it is a good that a decent society needs to ensure that no one is deprived of. Like hunger or illiteracy, it is a social bad that a decent society must be urgently concerned about.

Could a just society take the position that healthcare is simply another private good that people need to purchase with their own resources? That depends essentially upon the circumstances of social inequality. If in fact everyone in society has sufficient income to purchase healthcare or private insurance, then the "private good" approach may be sustainable. In a society in which there is substantial inequality and poverty, however, this position is untenable. Low- and middle-income people do not have the resources to purchase healthcare as a private good. And if social arrangements required this, then unavoidably there would be a disadvantaged population which was more disabled, more ill, and less long-lived than the more affluent population. This is plainly not a just or defensible outcome -- anymore than starvation or malnutrition in the midst of plenty is a just outcome.

The general answer our society has provided rests on two legs: employer-provided health insurance and state-funded insurance programs for the elderly, the disabled, and extremely poor children. What this system leaves out is a very large population of ineligible uninsured adults. And there are tens of millions of people in this situation. What does our society do to handle this situation? Very little. Basically we require hospitals to provide free care to extremely ill uninsured poor people, and we provide no avenue to affordable insurance for this group beyond the emergency room.

So, back to our question here : do people have right to healthcare? My answer is that it is a requirement of basic justice that all members of society should have access to healthcare, because this is essential to living a normal human life; that our society essentially recognizes this fact about justice (witness the emergency room contingency); but that this society does a simply terrible job of satisfying this requirement of justice. The tens of millions of people who are uninsured because they cannot afford to privately purchase health insurance are sufficient evidence for that.

So what is the solution? It seems inescapable that there needs to be a system of publicly provided and means-adjusted universal health coverage. This doesn't mean a national health system. It doesn't even necessarily mean a single unified national health insurance program, or abolition of private insurance. But it does mean that we must succeed in designing and implementing an affordable option for those not served by the current patchwork quilt of coverage systems. (Several states such as Massachusetts and Maine have made bold attempts to do this.) To date, however, we have not faced up to this simple requirement of justice. Let us look at the moral issue honestly and let us design a just and sustainable system.

(Philosopher Norm Daniels has thought about these issues deeply for many years. His recent book, Just Health: Meeting Health Needs Fairly, is a great contribution.)