Healthcare for All Is Essential… and It’s Not Enough

The major Democratic presidential candidates are pushing for healthcare for all, which is undoubtedly a critical priority given evidence that as many as 35,000 people die each year due to lack of healthcare.[1] However, if the only thing we do is guarantee universal health care, we will miss a huge opportunity to tap into the crux of why Americans are so unhealthy. Providing health is far more a matter of changing the social conditions that undermine health than it is of ensuring treatment once those conditions have resulted in chronic disease.

Americans are distinctly less healthy than people in most developed countries. We have the lowest life expectancy of 11 comparable countries at 78.6, while the average of the other countries is 82.2.[2]

Most comparisons of Americans’ health with that of people in other developed countries emphasize the differences in the availability of health. But that analysis overlooks more critical differences in the social conditions of these nations. Americans are sicker because we have greater poverty, discrimination, and economic inequality.

The United States has the third-highest rate of poverty among thirty-five developed countries, at 16.8 percent.[3] Moreover, 20 percent of our children live in poverty, a rate higher than thirty other developed countries. People who grow up in poverty are a higher risk of having cardiovascular disease as adults.[4] Greg Miller and his colleagues, who study the impact of childhood stress on health, have shown that social threat, which is higher in poorer families, compromises children’s immune system and drives inflammatory processes that contribute to obesity, diabetes, and ultimately cardiovascular disease. Even when young people who were raised in poverty escape from it as adults, they have higher rates of inflammatory processes that are linked to cardiovascular disease.[5] The only exception to this is if a person raised in poverty says that their mother was nurturing .[6]

Discrimination is another major influence on Americas health. Why do well-educated white men in America live an average of fourteen years longer than poorly educated black men?[7] It is almost certainly because African-American men experience more stress. According to the Pew Research Center,[8] 71% of African-Americans report experiencing discrimination regularly or occasionally. Jules P. Harrell, Sadiki Hall, and James Taliaferro, researchers at Howard University, reviewed research on the effects of discrimination on physiology.[9] People exposed to discrimination react with classic stress responses — elevated blood pressure, increased heart rate, changes in skin conductance, and greater arterial pressure. And, as Greg Miller’s work shows, chronic stress contributes to inflammatory processes that lead to obesity, diabetes, and cardiovascular disease.

Of course, it is not just African-Americans who experience discrimination. That Pew Research Center report also indicated that 52% of Hispanics and 30% of Caucasians report experiencing discrimination regularly or occasionally. Another Pew survey[10] found that about half of Muslims reported experiencing an incident of discrimination in the previous year. Forty-two percent of gay or bisexual adults report experiencing discrimination.[11] And keep in mind that poor people of any race are discriminated against, especially if they are homeless.[12] We should therefore not be surprised to learn that poor people have higher rates of asthma, obesity, diabetes, depression, high blood pressure, and heart attacks.[13]

And then there is economic inequality. On this one, we are number one.[14,15] Countries with more inequality have high rates of psychological and behavioral problems and more premature death. Disparity affects all but the very rich. One of the primary reasons lack of equality affects health is that people have more frequent stressful encounters, with people above or below them in the social hierarchies of unequal societies.[15]

The U.S. spends $2.3 trillion a year on healthcare.[16] Our per capita costs are twice the average of other developed countries. About 87% of the money goes to treating people for diseases that are preventable. [17] We will not achieve significant improvements in our health until we address the social conditions that are making so many people sick.

Reference List

1. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. American journal of public health. 2009;99(12):2289–2295.

2. Gonzales S, Sawyer B. How does U.S. life expectancy compare to other countries? Kaiser Family Foundation. https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-u-s-lowest-life-expectancy-birth-among-comparable-countries. Published 2017. Accessed June 13, 2018.

3. OECD Family Database. CO2.2: Child poverty. OECD Publishing. Family Database Web site. http://www.oecd.org/els/soc/CO_2_2_Child_Poverty.pdf. Published 2018. Updated July 13, 2018. Accessed.

4. Miller GE, Chen E, Parker KJ. Psychological stress in childhood and susceptibility to the chronic diseases of aging: moving toward a model of behavioral and biological mechanisms. Psychological Bulletin. 2011;137(6):959–997.

5. Miller GE, Chen E, Fok AK, et al. Low early-life social class leaves a biological residue manifested by decreased glucocorticoid and increased proinflammatory signaling. Proceedings of the National Academy of Sciences. 2009;106(34):14716–14721.

6. Miller GE, Lachman ME, Chen E, Gruenewald TL, Karlamangla AS, Seeman TE. Pathways to resilience: Maternal nurturance as a buffer against the effects of childhood poverty on metabolic syndrome at midlife. Psychological Science. 2011;22(12):1591–1599.

7. Olshansky SJ, Antonucci T, Berkman L, et al. Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health affairs (Project Hope). 2012;31(8):1803–1813.

8. Center PR. On Views of Race and Inequality, Blacks and Whites Are Worlds Apart. 2016.

9. Harrell JP, Hall S, Taliaferro J. Physiological responses to racism and discrimination: an assessment of the evidence. American Journal of Public Health. 2003;93(2):243–248.

10. Center PR. U.S. uslims Concerned About Their Place in Society, but Continue to Believe in the American Dream”. 2017.

11. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American journal of public health. 2001;91(11):1869–1876.

12. Johnstone M, Jetten J, Dingle GA, Parsell C, Walter ZC. Discrimination and well-being amongst the homeless: the role of multiple group membership. Frontiers in psychology. 2015;6:739–739.

13. Affairs H. Health, Income, And Poverty: Where We Are And What Could Help. Health Affairs Health Policy Brief. 2018; DOI: 10.1377/hpb20180817.901935.

14. Wilkinson R, Pickett K. The spirit level: Why equality is better for everyone. Penguin UK; 2010.

15. Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Soc Sci Med. 2015;128:316–326.

16. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: Library of Congress;2016.

17. Services CfMaM. National Health Expenditures 2017 Highlights. PDF accessed at https://wwwcmsgov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheethtml April 20, 2019. 2018.