Elsevier

The Lancet

Volume 389, Issue 10077, 8–14 April 2017, Pages 1431-1441
The Lancet

Series
Inequality and the health-care system in the USA

https://doi.org/10.1016/S0140-6736(17)30398-7Get rights and content

Summary

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.

Introduction

As economic inequality in the USA has deepened, so too has inequality in health. Almost every chronic condition, from stroke to heart disease and arthritis, follows a predictable pattern of rising prevalence with declining income.1 The life expectancy gap between rich and poor Americans has been widening since the 1970s,2 with the difference between the richest and poorest 1% now standing at 10·1 years for women and 14·6 years for men.3 The health of poor communities is often neglected: for example, in Flint (MI, USA), a de-industrialised, impoverished, and predominately African-American city, public officials dismissed evidence that children were being exposed to toxic levels of lead in the city's drinking water for several months.4

Attention to economic inequality intensified after the Occupy Wall Street movement decried the rising wealth and power of the richest 1%. This movement popularised research by the economists Piketty and Saez5 that revealed levels of income inequality unrivalled since the stock market bubble of the 1920s. The share of total income going to the top 1% of earners has more than doubled since 1970 (figure 1),6 while most workers in the USA have experienced slow income growth.7 As measured by the Gini coefficient, a standard metric of income inequality, the USA is now more unequal than all but three other countries (Chile, Mexico, and Turkey) in the Organization for Economic Co-operation and Development (OECD). The most equal countries are Denmark, Slovenia, Norway, and Slovakia.

The surge in top incomes has magnified inequality in wealth (ie, assets). Since 1986, the top 0·1% of households (those with assets exceeding US$20 million) has accumulated nearly half of all new wealth, and now controls as much wealth as the bottom 90%, whose share has fallen steadily.8

Key messages

  • Economic inequality in the USA has been increasing for decades and is now among the highest in developed countries.

  • Differences in life expectancy have been widening, with the wealthiest Americans now living 10–15 years longer than the poorest.

  • Despite coverage gains from the Affordable Care Act, about 27 million Americans remain uninsured—a number that is likely to increase under the reforms advocated by Republicans now empowered in Washington, DC.

  • Both overall and government health spending are higher in the USA than in other countries, yet inadequate insurance coverage, high cost sharing by patients, and geographical barriers restrict access to care for many.

  • Financing of health care in the USA is regressive, with poor and middle-class individuals paying a larger share of their incomes for care than the affluent, thereby deepening inequalities in disposable income.

  • Rising insurance premiums for employer-sponsored private coverage have eroded wage gains for middle-class Americans.

  • Medical indebtedness is common among both insured and uninsured Americans, and often leads to bankruptcy.

  • To achieve health-care equality, a non-market financing scheme that treats health care as a human right is essential.

Wealth inequality between racial and ethnic groups in the USA is especially striking, and is several times greater than income inequality. In 2013, median family wealth for the non-Hispanic white population was ten times that of Hispanics and more than 12 times that of African-Americans.9 The racial wealth gap results from historical factors dating back to slavery—many of which persist—including legalised racial segregation in the pre-civil rights era, pervasive job and housing discrimination, exclusionary city zoning laws, unequal education, and inheritance laws that perpetuate past inequalities.10

Although top incomes have risen, so has extreme poverty. More than 1·6 million households in the USA, including 3·5 million children, survive on incomes of less than $2 per person per day—WHO's definition of extreme poverty; this number has more than doubled since the 1990s.11

The health-care system could soften the effects of economic inequality by delivering high-quality care to all. Yet the institutions and financing patterns of the health-care system in the USA—by far the world's most expensive12–cause it to fall short of this ideal. Although inequalities exist to some extent in every health-care system, they are particularly stark in the USA. Unequal access to medical services is likely to contribute to disparities in health status, while rising costs (for both the insured and uninsured) reduce disposable incomes, particularly burdening low-income households.

Many patients cannot afford the care they need, and often forgo medical care altogether. For example, 19% of non-elderly adults in the USA who received prescriptions in 2014 (after full implementation of the Affordable Care Act [ACA]) could not afford to fill them.13 Millions of middle-class families have been bankrupted by illness and medical bills.14 Meanwhile, very wealthy Americans are turning to so-called concierge practices that offer lengthy office visits and unfettered access to specialists.

This Series paper examines how the health-care system in the USA contributes and responds to inequality. We focus our attention on the association between inequality and the medical care system.

We first review how social position influences Americans' access to medical services and the quality of those services. The uninsured face the greatest barriers to care, but many insured Americans are also unable to afford medical care because of cost sharing. Although race-based disparities in quality are well documented, the low quality scores of doctors and hospitals serving poor communities might reflect patients' deprived social circumstances rather than their providers' performance. We also review how the health-care costs borne by households—in the form of insurance premiums, taxes, and out-of-pocket payments—exacerbate income inequality, forcing many Americans to cut back on food and other necessities, and contributing to most personal bankruptcies. We conclude by discussing the historical context for today's health-care inequalities, and propose options for reform.

Section snippets

Inequality and access to care

Income-related disparities in access to care are far wider in the USA than in other wealthy countries.15 Before the 2010 passage of the ACA, which progressively expanded health insurance coverage, 39% of Americans with below-average income reported not seeing a doctor for a medical problem because of cost, compared with 7% of low-income Canadians and 1% of those in the UK.16 Inequality in access to care is particularly stark in Southern states. For example, in Texas, Mississippi, and Florida,

Inequality and quality of care

For many conditions, increased quality is implied by, and inseparable from, improved access to care. An increased frequency of primary care visits, for example, is associated with improved control of diabetes.55 Similarly, among patients who developed an acute myocardial infarction, the uninsured were 38% more likely (and the underinsured 21% more likely) than the well insured to delay seeking emergency care.56

Yet it is unclear whether income-related disparities in access to care are

Health-care financing inequality

The USA finances medical care through a complex network of public and private insurance programmes, as well as substantial direct payments by patients. Figure 3 shows the proportion of Americans covered by the main insurance programmes, and the major sources that fund health care. Taken together, government insurance programmes—principally, Medicare, Medicaid, and military health care—account for 42% of personal health-care expenditures.72 Yet this figure substantially understates the

Medical bills and financial hardship

The health-care financing system in the USA leaves millions of Americans facing medical bills that deplete their assets and drive them into debt. One in four non-elderly adults younger than 65 years (and one in three with annual household incomes <$50 000) reported difficulty paying medical bills in 2015; more than half of these individuals owe more than $2500.85 People with deductibles higher than $1500 (or families with deductibles >$3000) and worse health than the overall population are

A longer lens on health reform

A century ago, medical care in the USA had little influence on health or wealth. Burgeoning medical capabilities and costs in the 20th century made health care an industry ripe for corporate investment and profit. The transformation from a largely charitable service to a market-driven enterprise ensued.

Markets distribute goods on the basis of purchasing power, and for mostly non-discretionary purchases, such as medical care, this results in particularly lopsided financial burdens. In many other

Conclusion

Many physicians in the USA are working to advance health-care justice. But increased efforts in this direction are needed. The brave cadre of colleagues who face constant threat for delivering abortion services (which are disproportionately needed by poor women) must be supported and augmented, especially as anti-choice politicians now hold sway in Washington, DC. Doctors should follow the lead of trainees, such as those in the WhiteCoats4BlackLives movement, who have spoken out against the

Search strategy and selection criteria

We searched PubMed and Google Scholar using the following terms: “health care quality” OR “quality of care” AND “primary care” OR “specialty care” OR “specialist” OR “hospital” OR “surgery” OR “cancer” OR “outpatient” AND “inequality” OR “unequal” OR “disparities” AND “US” OR “United States”; “access to care” OR “health care access” OR “barriers to care” AND “inequality” OR “unequal” OR “disparities” AND “poor” OR “poverty” OR “wealthy” OR “income” AND “US” OR “United States”; “regressive” OR

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