[Senate Hearing 113-820]
[From the U.S. Government Publishing Office]
S. Hrg. 113-820
DYING YOUNG: WHY YOUR SOCIAL AND ECONOMIC STATUS MAY BE A DEATH
SENTENCE IN AMERICA
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING HEALTH RELATING TO SOCIAL AND ECONOMIC STATUS
__________
NOVEMBER 20, 2013
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina RAND PAUL, Kentucky
AL FRANKEN, Minnesota ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts
Pamela Smith, Staff Director
Lauren McFerran, Deputy Staff Director and Chief Counsel
David P. Cleary, Republican Staff Director
______
Subcommittee on Primary Health and Aging
BERNARD SANDERS, Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts LAMAR ALEXANDER, Tennessee (ex
TOM HARKIN, Iowa (ex officio) officio)
Sophie Kasimow, Staff Director
Riley Swinehart, Republican Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, NOVEMBER 20, 2013
Page
Committee Members
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Aging, opening statement................................... 1
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 2
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 36
Witnesses
Woolf, Steven, M.D., MPH, Director of The Center on Society and
Health, and Professor of Family Medicine and Population Health,
Virginia Commonwealth University, Richmond, VA................. 3
Prepared statement........................................... 5
Berkman, Lisa, Ph.D., Director of the Harvard Center for
Population and Development Studies and Thomas D. Cabot
Professor of Public Policy and Epidemiology, Harvard
University, Cambridge, MA...................................... 19
Prepared statement........................................... 21
Eberstadt, Nicholas, Ph.D., MPA, M.Sc., Henry Wendt Chair in
Political Economy, American Enterprise Institute, Washington,
DC............................................................. 24
Prepared statement........................................... 25
Kindig, David A., M.D., Ph.D., Emeritus Professor of Population
Health Sciences, University of Wisconsin School of Medicine and
Public Health, Madison, WI..................................... 37
Prepared statement........................................... 39
Shrader, Sabrina, Athens, WV..................................... 42
Prepared statement........................................... 44
Reisch, Michael, Ph.D., MSW, Daniel Thursz Distinguished
Professor of Social Justice, University of Maryland School of
Social Work, Baltimore, MD..................................... 45
Prepared statement........................................... 47
(iii)
DYING YOUNG: WHY YOUR SOCIAL AND ECONOMIC STATUS MAY BE A DEATH
SENTENCE IN AMERICA
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WEDNESDAY, NOVEMBER 20, 2013
U.S. Senate,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m. in
room SD-430, Dirksen Senate Office Building, Hon. Bernard
Sanders, chairman of the subcommittee, presiding.
Present: Senators Sanders, Baldwin, Murphy, and Warren.
Opening Statement of Senator Sanders
Senator Sanders. Let me thank our wonderful panelists for
being here to discuss an issue of huge consequence for our
country. I think what will be happening during the morning is
Senators will be drifting in and out. It is a particularly busy
time. But the issue that we are going to be discussing is
something that needs to be worked on a whole lot.
The first point that has to be made is that in this great
country, we see huge disparities in terms of how long people
live; life expectancy. I think people would be shocked if they
knew that in this country--just between neighborhoods in a
given city or areas of our country--you will find in one place
people living rather long and healthy lives, and in other parts
of the country, people living much shorter lives often plagued
by illness.
One point that I want to make is that when we talk about
poverty, I think a lot of people say, ``Well, somebody is poor
who maybe lives in inadequate housing, and that is just too
bad,'' or may not have a good automobile, or may not even be
able to go to college, or afford to go to college; all of that
is true. But poverty and the stress of poverty is much, much
more than that, and in many ways in our country, the stress of
poverty is a death sentence which results in significantly
shorter life expectancy.
One of our witnesses today, Dr. Kindig, published a paper
earlier this year in ``Health Affairs'' showing that female
mortality rose--rose--in the United States in 43 percent of
U.S. counties between 1992 and 2006. That women in those
counties are actually dying at a younger age.
The goal of everything that we do in this sense, is that we
strive to figure out ways in which people can live longer and
happier lives. That is really what it is about. People may
disagree about how to get there, but that is the goal. But when
we find that female mortality rose in 43 percent of U.S.
counties between 1992 and 2006, that is a profound reality that
has got to be dealt with.
Right here in the Nation's Capital, in Washington, DC, life
expectancy varies from 77 years in the District to 84 years in
Montgomery County just a few metro stops away; a 7 year
difference in life expectancy for women. The county with the
highest life expectancy is Marin County in northern California
where the average life expectancy is 85 years, which stacks up
pretty well with the rest of the world.
We, as a Nation, are behind many other countries in terms
of life expectancy and that, in itself, is worthy of serious
discussion. In Marin County, CA, women live to be 85 years of
age, which is good. The lowest in the Nation is Perry County,
KY with an average life expectancy for women of 73 years; 12
years less in the United States of America.
For men, the highest life expectancy occurs in nearby
Fairfax County outside of Washington, DC where the average is
82 years for men; that is pretty good. This compares to a life
expectancy of 64 years for men in McDowell County, WV where one
of our guests is from. That is an 18-year gap within the United
States of America. Men born in Marin County will live 18 years
longer than men in McDowell County, WV.
One of our witnesses today, Sabrina Shrader, grew up in
McDowell County, WV, where men have the same average life
expectancy as men in Botswana or Namibia. Women in McDowell
County have shorter lives than women in El Salvador or
Mongolia, and the gaps in life expectancy within our country
are widening, and today's hearing will call attention to this
troubling fact.
We know that there are disparities in life expectancy based
on gender, race, and socioeconomic status. It is becoming
increasingly clear that education plays a critical role of
determining how long someone will live. Those without a high
school education in the United States, of all races, live
shorter lives and experience poorer health than those with
higher levels of education. In fact, a white woman without a
high school education saw her life expectancy drop 5 years from
1990 to 2008.
The issue that we want to explore today is why that is so.
Why we are seeing, in some cases, people in our country living
shorter lives than their parents did? We want to look at why
this disparity exists. We want to understand almost the
physiology of what poverty is about.
What does stress mean? What does it mean if you wake up in
the morning, and you are not quite sure if you and your kids
are going to have enough food? If you do not have a job, what
does it mean to you, personally, and how does that result
overall in shortening your life?
This is a very important and profound discussion, and we
are so pleased to have our knowledgeable panelists with us. I
see Senator Warren here.
Senator Warren, do you want to make some opening remarks?
Statement of Senator Warren
Senator Warren. Thank you very much, Chairman Sanders.
Thank you very much for calling this hearing and thank you
all for being with us today. I will be brief because I want to
get to your questions so that we can ask more, but I do want to
say after reading our notes, this is something you and I have
talked about a lot.
Our witnesses have highlighted how the health of our
citizens is tied to our economy. We know that income is one of
the best predictors of life expectancy, as you have pointed
out, but I would add, that it is also one of the best
indicators of other health problems--asthma, diabetes, mental
health disorders, the list is just starting--in which we know
that income has a profound influence on the likelihood of
having those problems and the severity of those problems.
So when we talk about reducing costs in the healthcare
system and improving the health of Americans generally, I think
we have to take a step back and take a very hard look at what
is happening to the economy in the United States; how these
things fit together. How greater income inequality is having a
profound effect, not only on the economic life of Americans,
but also on their health and the health of their children.
With that, I want to go straight to hearing from our
witnesses if we can.
Thank you, Mr. Chairman.
Senator Sanders. We certainly can, and thanks very much.
Our first witness is Dr. Steven Woolf. Dr. Woolf is a
professor of family medicine and population health, and
director of the Center on Society and Health at the Virginia
Commonwealth University; an expert on primary care and public
health. He received his training at Emory University, Johns
Hopkins University, and Virginia Commonwealth University, and
has worked for 25 years in academic and public policy settings.
Dr. Woolf, thanks so much for being with us.
STATEMENT OF STEVEN WOOLF, M.D., MPH, DIRECTOR OF THE CENTER ON
SOCIETY AND HEALTH, AND PROFESSOR OF FAMILY MEDICINE AND
POPULATION HEALTH, VIRGINIA COMMONWEALTH UNIVERSITY, RICHMOND,
VA
Dr. Woolf. Thank you, Senator Sanders. Thank you, Senator
Warren. It is a pleasure to be here to testify on this
important issue.
Our Center, the Center on Society and Health study how
factors outside of healthcare shape health outcomes. One such
factor is income. The lower people's income, the earlier they
die and the sicker they live. The poor have higher rates of a
long list of diseases such as diabetes, heart disease,
depression, and disability, as Senator Warren mentioned.
But it is not just the poor. The health of working-class
and middle-class, and even upper-class Americans also rises and
falls with our socioeconomic status. Take this for example, 68
percent of American adults have an income that is more than
twice the poverty level. Suppose we boosted that number just
slightly from 68 percent to 70 percent and looked at the impact
on one disease, diabetes. That higher income would mean about
400,000 fewer cases of diabetes, saving $2.5 billion dollars
per year to treat that one disease.
If economic conditions matter so greatly to health and
healthcare costs, the reverse is also true. Harder times for
the middle class and the poor mean that Americans and their
children will get sicker and die earlier. Already, the health
of Americans is inferior to that of people in other high-income
countries.
I recently chaired an expert panel convened by the National
Research Council and the Institute of Medicine. We compared the
United States with 16 other high-income countries and found
that Americans die earlier and have higher rates of disease and
injury.
The U.S. health disadvantage exists for men and women, for
young and old, and as this table shows on the easel, across
multiple areas of health from infant mortality to traffic
fatalities, from teen pregnancies to diseases of the heart and
lungs, diabetes, and disability. American children are less
likely to reach age 5 than children in other rich Nations. Our
babies are less likely to reach their first birthday. Our rate
for premature babies is similar to sub-Saharan Africa.
The U.S. health disadvantage is not restricted to the poor
and minorities; it is seen among all social classes, the rich
and poor, more-educated and less-educated Americans. But the
problem is clearly worse for those with less-income, and the
socioeconomic picture for the average American family is not
good.
Although in aggregate our Nation is wealthy, we have high
rates of income inequality, and thus, high poverty rates. For
three decades, we have had the highest child poverty rate in
the industrialized world. These conditions affect health and
when we die.
Consider my State, Virginia, home to the two most affluent
counties in the country, but also home to rural areas with deep
poverty. Our Center found that 25 percent of all deaths in
Virginia would be averted if everyone had the death rate of
Virginia's five most affluent areas. Let me repeat, that is one
out four deaths.
This reflects not just the difference in the loss of the
people who live in those counties, but the economic and social
capital of the communities themselves. These differences
produce big gaps in life expectancy across a matter of miles.
We produced a metro map of Washington, DC showing that
lives are 7 years shorter in DC than in the Maryland suburbs at
the end of the Red Line, as Senator Sanders mentioned.
In New Orleans, if you can show the next map, we found that
a baby born in ZIP Code 70112 can expect to live 25 fewer years
than a baby born in ZIP Code 70124.
Neighborhoods in Boston and Baltimore have a lower life
expectancy than Ethiopia and Sudan. Azerbaijan has a higher
life expectancy than areas of Chicago.
What is the take away for Congress? First of all, it is
that economic policy is not just economic policy, it is health
policy. Pocketbook issues affect disease rates and how long
Americans live. Strategies to strengthen the middle class and
relieve poverty can prevent costly diseases like diabetes,
which leads to the second major takeaway: relieving economic
hardship for Americans is a smart way for Congress to control
medical spending.
Spiraling healthcare costs are a big concern here in
Congress and in corporate America. We are all searching for
ways to bend the cost curve. What better way than reducing the
flow of disease into the system? Earlier I mentioned that 25
percent of all deaths in Virginia could be averted. No form of
healthcare reform and no treatments by doctors and hospitals
can rival that kind of effect.
The third takeaway is that health is affected not only by
what is in your bank account, but also by policies that put
people on the road to economic success such as helping our
young people get a good education. Investments in early
childhood are key to our Nation's future and to their life
expectancy. Legislation that puts American families on a
stronger footing, and strengthens the physical and social
environment in which they live, like those neighborhoods in New
Orleans and Baltimore, can be good for the economy and public
health, thereby curbing healthcare costs.
The opposite is true: cutting these programs in an attempt
to save money could save nothing if it makes people sicker and
thereby drives up medical spending. A sicker population means a
sicker workforce, making American businesses less competitive
and our military less fit for duty. Our economy, and national
security, cannot afford this and nor can our people.
Thank you.
[The prepared statement of Dr. Woolf follows:]
Prepared Statement of Steven Woolf, M.D., MPH
Thank you, Senators Sanders and Burr. I'm Steven Woolf and I
appreciate the opportunity to testify this morning. I'm a family
physician and I direct Virginia Commonwealth University's Center on
Society and Health. Our center studies how factors outside of health
care shape health outcomes. One such factor is income. This committee
needs no reminders about the importance of income to American families.
What's perhaps less apparent is how greatly economic conditions affect
the health of adults and children--and by extension the costs of health
care.
The lower people's income, the earlier they die and the sicker they
live. The poor have higher rates of a long list of diseases such as
diabetes, heart disease, depression, and disability. Children raised in
poverty grow up with more illnesses.
But it's not just the poor. The health of working class and middle
class and even upper class Americans also rises and falls with their
socioeconomic status. Let's look at an example: 68 percent of American
adults have an income that is more than twice the poverty level.
Suppose we boosted that number just slightly, from 68 percent to 70
percent and looked at the impact on one disease--diabetes. That higher
income would mean about 400 million fewer cases of diabetes, saving $2
billion per year to treat that disease.
If economic conditions matter so greatly to health and health care
costs, the reverse is also true. Subjecting the middle class and the
poor to harder times means that Americans, and their children, will get
sicker and die earlier.
Already, the health of Americans is inferior to that of people in
other high-income countries. I recently chaired an expert panel
convened by the National Research Council and the Institute of
Medicine. We compared the United States with 16 other high-income
countries and found that Americans die earlier and we have higher rates
of disease and injury. This U.S. health disadvantage exists for men and
women, for young and old, and across multiple areas of health, from
infant mortality to traffic fatalities, from teen pregnancies to
diseases of the heart and lung, diabetes, and disability.
American children are less likely to reach age 5 than children in
other rich nations. Our babies are less likely to reach their first
birthday. Our rate for premature babies is similar to sub-Saharan
Africa and our teenagers are sicker than teens elsewhere.
The U.S. health disadvantage is not restricted to the poor and
minorities. It's seen among all social classes, the rich and poor,
more-educated and less-educated, whites and people of color.
But the problem is clearly worse for those with less income, and
the socioeconomic picture for the average American family is not good.
Although in aggregate our Nation is wealthy, we have notoriously high
rates of income inequality and thus for three decades our relative
poverty rates, especially child poverty rates, have been the highest in
the industrialized world. America is the land of opportunity but
studies show that the ability of a poor child to climb the economic
ladder and escape poverty is lower here than elsewhere.
These conditions affect health--and when we die. Consider my State,
Virginia--home to the two most affluent counties in the country but
also home to rural areas with deep poverty. Our center found that 25
percent of all deaths in Virginia would be averted if everyone had the
death rate of Virginia's five most affluent areas. Let me repeat--one
out of four deaths.
What this reflects is not just a difference in the wealth of the
people living in those counties but the economic vitality,
infrastructure, and social capital of the communities themselves.
Together, these factors produce vast differences in life expectancy
across small distances. We produced this metro map of Washington, DC,
showing that lives are 7 years shorter in DC than in the Maryland
suburbs at the end of the Red Line. In New Orleans, we found that a
baby born in zip code 70112 can expect to live 25 fewer years than a
baby born in zip code 70124. Neighborhoods in Boston and Baltimore have
a lower life expectancy than Ethiopia and Sudan. Azerbaijan has a
higher life expectancy than areas of Chicago.
What's the takeaway for Congress? First of all, economic policy is
not just economic policy--it's health policy. Pocketbook issues affect
disease rates and how long Americans will live. Strategies to
strengthen the middle class and relieve poverty can prevent costly
diseases like diabetes, which leads to the second major takeaway:
relieving economic hardship for Americans is a smart way for Congress
to control medical spending. Spiraling health care costs are a big
concern here in Congress and in corporate America. We are all searching
for ways to bend the cost curve. What better way than reducing the flow
of disease into the system? Earlier I mentioned that 25 percent of all
deaths in Virginia could be averted. No form of health care reform, and
no treatments by doctors and hospitals, can rival that kind of effect.
The third takeaway is that health is affected not only by what's in
your bank account but also, perhaps more importantly, by policies that
put people on the road to economic success, such as helping our young
people get a good education. Deaths from diabetes are three times
higher for Americans without a high school diploma. Investments in
early childhood are keys to our Nation's future, and to their life
expectancy. The laws you pass that strengthen the physical and social
environment in which Americans live, like those neighborhoods in New
Orleans and Baltimore, can both grow the economy and also save lives
and curb health care costs.
And now to my last point: Many of these programs are in jeopardy
because of fiscal pressures to cut spending. Education reform, job
training, urban renewal, and safety net programs may not seem like
health expenditures but they affect health and medical spending
nonetheless. There are forms of discretionary spending that are keys to
curbing entitlement spending on health care.
Slashing these programs could be counterproductive. I urge Congress
to consider how proposed cuts outside the health sector will affect
disease rates. Cutting a program to save money may save nothing if it
makes people sicker and thereby drives up the costs of health care. And
a sicker population means a sicker workforce, making American
businesses less competitive and our military less fit for duty. Our
economy and national security can't afford this, and nor can our
people.
______
Attachment By Steven H. Woolf * and Paula Braveman
Where Health Disparities Begin: The Role of Social And Economic
Determinants--And Why Current Policies May Make Matters Worse
Abstract: Health disparities by racial or ethnic group or by income
or education are only partly explained by disparities in medical care.
Inadequate education and living conditions--ranging from low income to
the unhealthy characteristics of neighborhood and communities--can harm
health through complex pathways. Meaningful progress in narrowing
health disparities is unlikely without addressing these root causes.
Policies on education, child care, jobs, community and economic
revitalization, housing, transportation, and land use bear on these
root causes and have implications for health and medical spending. A
shortsighted political focus on reducing spending in these areas could
actually increase medical costs by magnifying disease burden and
widening health disparities.
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* Steven H. Woolf ([email protected]) is the director of the Center on
Human Needs and a professor in the Department of Family Medicine at
Virginia Commonwealth University, in Richmond.
Paula Braveman is the director of the Center on Social
Disparities in Health at the University of California, San Francisco
(UCSF), and a professor of family and community medicine at UCSF.
---------------------------------------------------------------------------
In 2003 the landmark Institute of Medicine report Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care
drew needed attention to disparities in the health care of racial and
ethnic minorities.\1\ The response from the health care and policy
communities included new initiatives to standardize treatments for
racial and ethnic minorities, heighten providers' cultural competency,
and increase minority representation among health care professionals.
Although some disparities in health care have narrowed, disparities
in the health of minority and disadvantaged populations have persisted.
Since the 1960s, the mortality rate for blacks has been 50 percent
higher than that for whites, and the infant mortality rate for blacks
has been twice as high as that for whites.\2\ \3\ Health disparities
exist even in health care systems that offer patients similar access to
care, such as the Department of Veterans Affairs,\4\ which suggests
that disparities originate outside the formal health care setting.
social determinants of health
Understanding health disparities requires a fresh look at the
determinants of health itself, the most obvious being intrinsic
biological attributes such as age, sex, and genes. Some other risk
factors that affect health are referred to as ``downstream''
determinants because they are often shaped by ``upstream'' societal
conditions. Downstream determinants include medical care; environmental
factors, such as air pollution; and health behaviors, such as smoking,
seeking or forgoing medical care, and not adhering to treatment
guidelines.\5\
Exposure to these determinants is influenced by ``upstream'' social
determinants of health--personal resources such as education and income
and the social environments in which people live, work, study, and
engage in recreational activities. These contextual conditions
influence people's exposure to environmental risks and their personal
health behaviors, vulnerability to illness, access to care, and ability
to manage conditions at home--for example, the ability of patients with
diabetes to adopt necessary lifestyle changes to control their blood
sugar.\6\ \7\ \8\ \9\ \10\ \11\ \12\ Social determinants are often the
root causes of illnesses and are key to understanding health
disparities.
Income. Income--with education, one of the most familiar social
determinants--has a striking association with health (Exhibit 1).\11\
Paula Braveman and Susan Egerter have shown that U.S. adults living in
poverty are more than five times as likely to report being in fair or
poor health as adults with incomes at least four times the Federal
poverty level.\8\ The income-health relationship is not restricted to
the poor: Studies of Americans at all income levels reveal inferior
health outcomes when compared to Americans at higher income levels.\10\
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
That income is important to health might not be surprising to some,
but the magnitude of the relationship is not always appreciated. For
example, Nancy Krieger and colleagues estimated that 14 percent of
premature deaths among whites and 30 percent of premature deaths among
blacks between 1960 and 2002 would not have occurred if everyone had
experienced the mortality rates of whites in the highest income
quintile.\13\ Steven Woolf and coauthors calculated that 25 percent of
all deaths in Virginia between 1996 and 2002 would have been averted if
the mortality rates of the five most affluent counties and cities had
applied statewide.\14\ Peter Muennig and colleagues estimated that
living on incomes of less than 200 percent of the Federal poverty level
claimed more than 400 million quality-adjusted life-years between 1997
and 2002, meaning that poverty had a larger effect than tobacco use and
obesity.\15\
Such estimates rely on certain assumptions and do not prove
causality. However, the consistency of the evidence supports the
conclusion that income, or the conditions associated with income, are
important determinants of health.
Education. Like income, education has a large influence on health
(Exhibit 2). An extensive literature documents large health disparities
among adults with different levels of education. Adults without a high
school diploma or equivalent are three times as likely as those with a
college education to die before age 65.\16\ The average 25-year-old
with less than 12 years' education lives almost 7 fewer years than
someone with at least 16 years' education.\10\ Children's health is
also strongly linked to their parents' education.\10\
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
According to Irma Elo and Samuel Preston, every additional year in
educational attainment reduces the odds of dying by 1-3 percent.\17\
Ahmedin Jemal and colleagues reported that approximately 50 percent of
all male deaths and 40 percent of all female deaths at ages 25-64 would
not occur if everyone experienced the mortality rates of college
graduates.\18\ Woolf and coauthors estimated that giving all U.S.
adults the mortality rate of adults with some college education would
save seven lives for every life saved by biomedical advances.\19\
Stark racial or ethnic differences in education and income could
largely explain the poorer health of blacks and some other minorities.
The high school dropout rate is 18.3 percent among Hispanics, 9.9
percent among blacks, and 4.8 percent among non-Hispanic whites. The
proportion of Hispanic adults with less than 7 years of elementary
school education is 20 times that of non-Hispanic whites. Black and
Hispanic households earned two-thirds the income of non-Hispanic whites
and were three times as likely to live in poverty.\20\ As of 2009 white
households had 20 times the net worth of black households.\21\
A Web of Conditions. Education and income are elements of a web of
social and economic conditions that affect health (and influence each
other) in complex ways over a lifetime. These conditions include
employment, wealth, neighborhood characteristics, and social policies
as well as culture and beliefs about health--for example, the belief
that diseases are ordained by fate and therefore not preventable.
People with low education and income are more likely than their better-
educated, higher income counterparts to lack a job, health insurance,
and disposable income for medical expenses.
Education and income are also associated with behaviors that affect
health. Smoking is three times as prevalent among adults without a high
school diploma than among college graduates.\2\ Similar patterns exist
for other unhealthy behaviors, such as physical inactivity.
the role of neighborhoods and communities
Unhealthy behavior is partly a matter of personal choice, but
extensive evidence documents the strong influence of the environment in
which people live and work.\5\ \6\ \11\ \12\ One may desire to eat a
healthy diet but find nutritious foods too costly or live too far from
a supermarket that sells fresh produce.\5\ Parents might want to limit
the time their children spend in front of a television or computer in
favor of sending them outdoors for exercise, but their neighborhoods
may be unsafe or lack playgrounds or sidewalks.
The built environment--for example, the design of roads and
pedestrian routes--can thwart efforts to walk or bicycle to the store
or work. Poor and minority neighborhoods are often ``food deserts''
with limited access to healthy foods but numerous fast-food outlets.\5\
Schools in low-income neighborhoods often serve inexpensive processed
foods and rely on revenue from vending machine contracts that promote
soft drinks and high-calorie snacks.\5\
But behavior is not the whole story.\11\ \12\ Distressed homes and
neighborhoods can induce disease and contribute to disparities via
pathways unrelated to behavior.\8\ For example, housing can expose
occupants to lead and allergens. Bus depots, factories, highways, and
hazardous waste sites are often situated near low-income and minority
neighborhoods.\22\ Distressed communities have a notorious shortage of
health care providers, especially in primary care.
Social conditions are also important. Health may be compromised by
the chronic stress of living amid multiple adverse conditions, such as
poverty, unemployment, urban blight, and crime. Communities of color--
especially minority youth--are targets of advertising that promotes the
consumption of alcohol, tobacco, and high-calorie foods.\5\
Impoverished neighborhoods may have residents who are less able to
help their neighbors. These neighborhoods may also have reduced social
cohesion--which can influence health behavior; the sense of security
and social well-being experienced by members of the community; and the
ability of individuals within a community to join forces to advocate
for needed services.\11\ For example, minority neighborhoods with poor
social cohesion may be unable to mount effective political opposition
to decisions that will affect local schools or air quality.
Entrenched patterns reflecting long-standing disadvantage in low-
income and minority neighborhoods often perpetuate cycles of
socioeconomic failure. Employment opportunities and good schools may be
scarce. Low-income residents often cannot afford to move elsewhere.
Traveling across town to find a job--or a better one--or to reach a
supermarket or doctor may be difficult if public transportation is
unavailable or costly.
biological pathways to health disparities
Sandro Galea and colleagues recently estimated that of the 2.8
million deaths in the United States in 2000, 245,000 were attributable
to low education, 176,000 to racial segregation, 162,000 to low social
support, 133,000 to individual-level poverty, and 119,000 to income
inequality.\23\
How do these conditions claim lives? Research has identified
several plausible pathways. For example, people living with inadequate
resources often experience stress levels that can cause the brain to
stimulate endocrine organs to produce hormones, such as cortisol and
epinephrine, at levels that may alter immune function or cause
inflammation. Repeated or sustained exposure to these substances may
produce ``wear and tear'' on organs and precipitate chronic diseases
such as diabetes and heart disease.\11\ \24\
Other research suggests that the most profound health effects of
living conditions may be delayed consequences that unfold over the span
of a lifetime.\25\ Experiences in the womb and early childhood,
including stress, can have lasting effects that do not manifest
themselves until late adulthood--or even in the next generation. An
adult mother's childhood experiences can leave a biological imprint
that affects the neurological and mental development of her offspring.
Even the effects of genes can be modified by the environment. New
research in the field of epigenetics--the study of inherited changes in
gene expression--suggests that the social and physical environment can
activate the expression of genes and thus can determine whether a
disease develops. This epigenetic makeup can be passed on to children
and influence the occurrence of disease in more than one
generation.\11\ Although more remains to be investigated and
understood, the fact that many social determinants have an impact on
health makes scientific sense.
declining incomes and increasing inequality
Given that income contributes greatly to health disparities, the
decline in the average income of Americans since 1999 and other signs
of economic hardship are troubling. Between 2000 and 2009 food
insecurity (defined as limited or uncertain access to adequate food),
severe housing cost burdens (spending more than 50 percent of income on
housing), and homelessness increased in the United States.\20\ By 2010
the U.S. poverty rate had reached 15.1 percent, its highest percentage
since 1993.\26\
The gap between the rich and poor has been widening since 1968,
especially recently.\26\ Between 2005 and 2009 the share of wealth held
by the top 10 percent of the population increased from 49 percent to 56
percent. Over the same period, the average net worth of white
households fell by 16 percent, from $134,992 to $113,149; the average
net worth of black and Hispanic households fell by 53 percent (from
$12,124 to $5,677) and 66 percent (from $18,359 to $6,325),
respectively.\21\
The fact that the average American's income and wealth are
shrinking has important health implications. Since 1980, when the
United States ranked 14th in life expectancy among industrialized
countries, the U.S. ranking has been declining. By 2008 the United
States ranked 25th in life expectancy, behind such countries as
Portugal and Slovenia.\27\ The United States has also not kept pace
with other industrialized countries in terms of infant mortality and
other health indicators.\27\
Various explanations have been proposed, ranging from unhealthier
behavior on the part of Americans to deficiencies in the U.S. health
care system. However, a persistent question is whether U.S. health
status is slipping because of unfavorable societal conditions. Other
industrialized countries outperform the United States in education,
have lower child poverty rates, and maintain a stronger safety net to
help disadvantaged families maintain their health.
policies, macroeconomics, and societal structure
Economic opportunity, the vibrancy of neighborhoods, and access to
education and income are conditions set by society, not by physicians,
hospitals, health plans, or even the public health community. The
leaders who can best address the root causes of disparities may be the
decisionmakers outside of health care who are in a position to
strengthen schools, reduce unemployment, stabilize the economy, and
restore neighborhood infrastructure. Policymakers in these sectors may
have greater opportunity than health care leaders to narrow health
disparities. The key change agents may be those working in education
reform to help students finish high school and obtain college degrees,
and those crafting economic policies to create jobs and teach workers
marketable skills.
Even public health efforts to reduce smoking and obesity
demonstrate that policy can often achieve more than clinical
interventions. Policies to restrict indoor smoking and increase
cigarette prices did more to reduce tobacco use in the past 20 years
than relying on physicians to counsel smokers to quit.\28\
The most influential change agents in efforts to help Americans eat
well and stay active may be the agencies and business interests that
determine advertising messages, supermarket locations, school lunch
menus, after-school and summer sports programs, food labels, and the
built environment. Key actors include city planners, State officials,
Federal agencies, legislatures at both the State and Federal levels,
employers, school boards, zoning commissions, developers, supermarket
chains, restaurants, and industries ranging from soda bottlers to
transit companies. Initiatives by hospitals, medical societies, and
insurers to reduce health care disparities remain vital, but the front
line in narrowing health disparities lies beyond health care.
the ``health in all policies'' movement
Increasingly, governments and businesses are being encouraged to
consider the consequences to health, and to health disparities, of
proposed policies in transportation, housing, education, taxes, land
use, and so forth--a ``health in all policies'' approach. For example,
a city council might replace an abandoned warehouse with a public park
or offer tax incentives for supermarkets to locate in a ``food desert''
neighborhood. Health impact assessments are being commissioned to study
the potential health consequences of policies concerning such diverse
topics as minimum wage laws and freeway widening.\29\ The ``health in
all policies'' approach has been adopted by individual communities,
State governments, and Federal initiatives, including the interagency
health promotion council established under the Affordable Care Act of
2010.\30\
This holistic approach to public policy comes at the recommendation
of prestigious commissions sponsored by the World Health
Organization,\6\ MacArthur Foundation,\7\ and Robert Wood Johnson
Foundation.\8\ Studies in the Bay Area \31\ and New York City,\32\ for
example; the acclaimed 2008 documentary film Unnatural Causes \33\; and
major initiatives by the W.K. Kellogg Foundation,\34\ California
Endowment,\35\ and Robert Wood Johnson Foundation \36\ have all
reinforced the message that ``place matters.'' Armed with a new field
of research that collects data at the neighborhood level, communities
are beginning to document and rectify local social and environmental
conditions that foment health disparities.
linking social policy to health disparities
Although some academics and policymakers understand the health
impact of social determinants, the general public and other
policymakers do not always recognize that social policy and health
policy are intimately linked. Social policies are clearly of concern
for reasons other than their health consequences. The recession has
riveted the Nation's attention on the need for jobs and economic
growth. Politicians view the economic plight of voters as an election
issue.
The missing piece is that advocates for jobs, education, and other
issues often overlook the health argument in making their case or
calculating the return on investment. Public programs to address
failing schools, disappearing jobs, and needed community development
are under scrutiny as the fiscal crisis forces spending cuts to balance
budgets and reduce the national debt. Defending these programs requires
more than just making moral arguments for their retention and
expansion. It requires proponents to make a solid business case, but
the value proposition should include the medical spending avoided by
having these programs in place.
Advocates for education or jobs programs often list important
benefits, such as a more competitive workforce, job security, and
economic growth. However, they could gather more support, especially
from policymakers concerned about medical spending, by showing that
disease rates--and hence health care costs--are connected to education,
employment, and socioeconomic well-being.
For example, the health connection strengthens the business case
for education. Henry Levin and colleagues reported that interventions
to improve high school graduation rates among black males yield
$166,000 per graduate in net savings to the government as a result of
higher tax revenues and lower public health costs and crime rates.\37\
Muennig and Woolf estimated that the health benefits of reducing
elementary school classroom sizes yield $168,000 in net savings per
high school graduate.\38\ Robert Schoeni and coauthors estimated that
giving all Americans the health status of college-educated adults would
generate more than $1 trillion per year in health benefits.\39\
Making the connection between social determinants and medical
spending heightens the relevance of social policy to a pressing
national priority: the spiraling costs of health care, which have
alarmed elected officials, employers, health plans, and the public.
Whether any proposed remedy--from malpractice reform to the
implementation of accountable care organizations--can bend the cost
curve remains uncertain.
The gravitational pull of health care has kept the policy focus on
reorganizing care, implementing information technology, and reforming
the payment system, with less consideration of issues outside of
medicine--even though they might curb the flow of patients into the
system and reduce spending more dramatically. Bobby Milstein and
coauthors recently calculated that expanding health insurance coverage
and improving health care would do less to save lives and control
medical spending than policies to improve environmental conditions and
promote healthier behavior.\40\
Remedies outside of health care can both reduce the cost of care
and ameliorate health disparities. An example is diabetes, a disease of
rising prevalence and costs. Diabetes occurs among adults without a
high school diploma at twice the rate observed among college
graduates.\2\ This disparity should speak volumes to policymakers
seeking to control spending on this disease--and those tempted to cut
education budgets to finance health care.
why this matters now
These issues need attention now, for four reasons. First, this is a
time of worsening socioeconomic conditions and rising inequality,
fomented by the recession and economic policies. Higher disease burden,
greater medical spending, and widened disparities could result.
The programs that could cushion stresses on children and families
are now vulnerable to budget reductions.
Second, exposing children to today's adverse social conditions has
ramifications for the health of tomorrow's adults. It has already been
predicted that this generation could, for the first time in U.S.
history, live shorter lives than its predecessors because of the
obesity epidemic.\41\ Children's exposure to worsening socioeconomic
conditions from fetal life through adolescence could alter the
trajectory of their health, making them more likely to develop disease
later in life.\25\ These outcomes could intensify demands on a health
care system that is already too costly to sustain.
Third, the very programs that could cushion stresses on children
and families are now vulnerable to proposed budget reductions. Programs
that help people get an education, find a job that can lift a family
out of poverty, or provide healthy food and stable housing are being
eliminated to balance budgets. This strategy, however, could backfire
if it precipitates disease, drives more patients into the health care
system, and increases medical spending.
Fourth, presidential and congressional elections are fast
approaching, and many politicians are eager to exhibit their fiscal
conservatism by reducing the size of government and eliminating social
programs. The zeal to cut spending may discourage thoughtful
consideration of how such cuts might expose voters to greater illness
or harm the economy.
It may be naive to hope that elected officials will rise above
reelection concerns to address outcomes that will outlast their term in
office and promote the greater good. It may be more realistic to hope
that the public and policymakers will begin to connect the dots and see
health as a by-product of the environment in which Americans live. They
might come to see that decisions about child care, schools, jobs, and
economic revitalization are ultimately decisions about health--and the
costs of health care.
Social issues lack quick and easy solutions. Politics surrounds
questions of how best to educate children and improve the economic
well-being of American families. However, scientific knowledge now
makes it clear that the current movement to shrink investments in these
areas has implications for public health and the costs of medical care.
Fiscally prudent politicians (and voters) who learn about the medical
price tag associated with austere economic and social policies may
question the logic of ``cutting spending'' in ways that ultimately
increase costs.
For the health equity movement, the challenge is to clarify this
connection for policymakers and to not focus exclusively on how
physicians and hospitals can reduce disparities. Equitable health care
is essential, but health disparities will persist--as they have for
generations--until attention turns to the root causes outside the
clinic.
Note: The authors thank the research staff of the Virginia
Commonwealth University Center on Human Needs (Project on Societal
Distress) and of the Robert Wood Johnson Foundation Commission to Build
a Healthier America for source data cited in this article. The authors
also thank Karen Simpkins for assistance in producing the exhibits. The
Project on Societal Distress was funded by the W.K. Kellogg Foundation
(Grants P3008553, P3011306, and P3015544).
Endnotes
1. Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment:
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(DC): National Academies Press; 2003.
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3. Satcher D, Fryer GE, Jr., McCann J, Troutman A, Woolf SH, Rust
G. What if we were equal? A comparison of the black-white mortality gap
in 1960 and 2000. Health Aff (Millwood). 2005;24(2):459-64.
4. Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S.
Racial and ethnic disparities in the VA health care system: a
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5. Woolf SH, Dekker MM, Byrne FR, Miller WD. Citizen-centered
health promotion: building collaborations to facilitate healthy living.
Am J Prev Med. 2011;40(1 Suppl 1):S38-47.
6. Commission on Social Determinants of Health. Closing the gap in
a generation: health equity through action on the social determinants
of health; final report of the Commission on Social Determinants of
Health. Geneva: World Health Organization; 2008.
7. John D. and Catherine T. MacArthur Foundation Research Network
on Socioeconomic Status and Health. Reaching for a healthier life:
facts on socieconomic status and health in the United States. Chicago
(IL): MacArthur Foundation; 2008.
8. Braveman P, Egerter S. Overcoming obstacles to health. Princeton
(NJ): Robert Wood Johnson Foundation; 2008.
9. Link BG, Phelan J. Social conditions as fundamental causes of
disease. J Health Soc Behav. 1995;35:80-94.
10. Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E.
Socioeconomic disparities in health in the United States: what the
patterns tell us. Am J Public Health. 2010;100 (Suppl 1):S186-96.
11. Braveman P, Egerter S, Williams D. Social determinants of
health: coming of age. Annu Rev Public Health. 2011;32:381-98.
12. Adler NE, Rehkopf DH. U.S. disparities in health: descriptions,
causes, and mechanisms. Annu Rev Public Health. 2008;29:235-52.
13. Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E,
Kennedy M. The fall and rise of U.S. inequities in premature mortality:
1960-2002. PLoS Med. 2008;5(2):e46.
14. Woolf SH, Jones RM, Johnson RE, Phillips RL, Jr., Oliver MN,
Vichare A. Avertable deaths associated with household income in
Virginia. Am J Public Health. 2010;100(4):750-5.
15. Muennig P, Fiscella K, Tancredi D, Franks P. The relative
health burden of selected social and behavioral risk factors in the
United States: implications for policy. Am J Public Health.
2010;100(9):1758-64.
16. Heron M, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera
B. Deaths: final data for 2006. Nat Vital Stat Rep. 2009;57(14):1-134.
17. Elo IT, Preston SH. Educational differentials in mortality:
United States 1979-1985. Soc Sci Med. 1996;42(1):47-57.
18. Jemal A, Thun MJ, Ward EE, Henley SJ, Cokkinides VE, Murray TE.
Mortality from leading causes by education and race in the United
States, 2001. Am J Prev Med. 2008;34(1):1-8.
19. Woolf SH, Johnson RE, Phillips RL Jr., Philipsen M. Giving
everyone the health of the educated: an examination of whether social
change would save more lives than medical advances. Am J Public Health.
2007; 97(4):679-83.
20. Project on Societal Distress [home page on the Internet].
Richmond (VA): Virginia Commonwealth University, Center on Human Needs;
[cited 2011 Aug 25]. Available from: http://www.societaldistress.org/.
21. Taylor P, Kochhar R, Fry R, Velasco G, Motel S. Wealth gaps
rise to record highs between whites, blacks, and Hispanics. Washington
(DC): Pew Research Center; 2011.
22. Brulle RJ, Pellow DN. Environmental justice: human health and
environmental inequalities. Annu Rev Public Health. 2006;27:103-24.
23. Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati A. Estimated
deaths attributable to social factors in the United States. Am J Public
Health. 2011;101(8):1456-65.
24. McKewen B, Gianaros PJ. Central role of the brain in stress and
adaptation: links to socioeconomic status, health, and disease. Ann N Y
Acad Sci. 2010;1186:190-222.
25. Cohen S, Janicki-Deverts D, Chen E, Matthews KA. Childhood
socioeconomic status and adult health. Ann N Y Acad Sci 2010;1186:37-
55.
26. DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and
health insurance coverage in the United States: 2010 [Internet].
Washington (DC): Census Bureau; 2011 Sep [cited 2011 Sep 21]. (Current
Population Reports). Available from: http://www.census.gov/prod/
2011pubs/p60-239.pdf.
27. Organization for Economic Cooperation and Development. OECD
health data 2011--frequently requested data [Internet]. Paris: OECD;
2011 Jun 30 [cited 2011 Aug 25]. [Available from: http://www.oecd.org/
dataoecd/52/42/48304068.xls#'LE Total population at birth'!A1.]
28. Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of
health: a review of environmental and policy approaches in the
prevention of chronic diseases. Annu Rev Public Health. 2006;27:341-70.
29. Cole BL, Fielding JE. Health impact assessment: a tool to help
policymakers understand health beyond health care. Annu Rev Public
Health. 2007;28:393-412.
30. National Prevention, Health Promotion, and Public Health
Council. 2010 annual status report [Internet]. Washington (DC):
Department of Health and Human Services; 2010 Jul 1 [cited 2011 Aug
25]. Available from: http://www.hhs.gov/news/reports/
nationalprevention2010report.pdf.
31. Beyers M, Brown J, Cho S, Desautels A, Gaska K, Horsley K, et
al. Life and death from unnatural causes: health and social inequity in
Alameda County; executive summary [Internet]. Oakland (CA): Alameda
County Department of Health; 2008 Apr [cited 2011 Sep 21]. Available
from: http://www.barhii.org/press/download/unnatural_causes_report.pdf.
32. Myers C, Olson C, Kerker B, Thorpe L, Greene C, Farley T.
Reducing health disparities in New York City: health disparities in
life expectancy and death. New York (NY): New York City Department of
Health and Mental Hygiene; 2010.
33. National Minority Consortia of Public Television. Unnatural
causes . . . is inequality making us sick? [DVD]. San Francisco (CA):
California Newsreel; c2008.
34. W.K. Kellogg Foundation. Place matters: empowering local
leaders to build public will to address community needs [Internet].
Battle Creek (MI): WKKF; [cited 2011 Sep 21]. Available from: http://
www.wkkf.org/what-we-support/racial-equity/stories/empowering-local-
leaders-to-build-public-will-to-address-community-needs.aspx.
35. California Endowment. Building healthy communities: California
living 2.0 [Internet]. Los Angeles (CA): The Endowment; [cited 2011 Sep
21]. Available from: http://www.calendow.org/Article.aspx?id=134
&ItemID=134.
36. Robert Wood Johnson Foundation. Place and health: why
conditions where we live, learn, work, and play matter [Internet].
Princeton (NJ): RWJF; [cited 2011 Sep 21]. Available from: http://
rwjf.org/vulnerablepopulations/product.jsp?id=72288.
37. Levin HM, Belfield C, Muennig P, Rouse C. The public returns to
public educational investments in African-American males. Econ Educ
Rev. 2007;26(6):699-708.
38. Muennig PA, Woolf SH. Health and economic benefits of reducing
the number of students per classroom in U.S. primary schools. Am J
Public Health. 2007;97 (11):2020-7.
39. Schoeni RF, Dow WH, Miller WD, Pamuk ER. The economic value of
improving the health of disadvantaged Americans. Am J Prev Med.
2011;40(1 Suppl 1):S67-72.
40. Milstein B, Homer J, Briss P, Burton D, Pechacek T. Why
behavioral and environmental interventions are needed to improve health
at lower cost. Health Aff (Millwood). 2011;30 (5):823-32.
41. Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA,
Brody J, et al. A potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005;352 (1):1138-45.
COMMENTARY
Public Health Implications of Government Spending Reductions *
(By: Steven H. Woolf, MD, MPH)
Across the United States, concerns over budget deficits and a weak
economy have prompted Federal, State, and local governments to propose
controversial spending reductions to balance their budgets. Debates and
protests incited by these decisions dominate the news, but what is
their relevance to medicine? The reflexive answer might be that
government spending policies are relevant if they compromise health
care services, essential public health programs, or biomedical
research. However, the biggest threat to public health may come from
funding cuts outside the health sector. Namely, budget decisions that
affect basic living conditions--removing opportunities for education,
employment, food security, and stable neighborhoods--could arguably
have greater disease significance than disruptions in health care.
---------------------------------------------------------------------------
* Note: Author Affiliations: Virginia Commonwealth University
Center on Human Needs, Virginia Commonwealth University, Richmond.
Note: Corresponding Author: Steven H. Woolf, MD, MPH, Center on
Human Needs, Virginia Commonwealth University, West Hospital, 1200 East
Broad St, PO Box 980251, Richmond, VA 23298-0251 ([email protected]).
---------------------------------------------------------------------------
Health status is determined by more than health care. Education,
income, and the neighborhood environment exert great influence on the
development of disease--perhaps more than interventions by physicians
or hospitals.\1\ Consider the role of education. In 2007, adults with a
bachelor's degree were four times less likely to report fair or poor
health than those without a high school education.\2\ The prevalence of
diabetes among adults without a high school diploma was 13.2 percent,
more than double the prevalence among adults with a bachelor's degree
(6.4 percent).\2\ In 2008-9, the risk of stroke was 80 percent higher
among adults who lacked a high school diploma than among those with
some college education.\3\ At age 25, life expectancy is at least 5
years longer among college graduates than among those who did not
complete high school.\4\ Multiple factors explain the health disparity
associated with education. Educational attainment is inversely
associated with smoking and obesity,\3\ but it is also a pathway to
better jobs, benefits (including health insurance), and financial
security--each of which conveys health advantages.
Families with financial insecurity face hardships that often take
priority over health concerns. These families tend to eat poorly, forgo
exercise, and skip medications to stretch their budget. Low incomes
force many to live in unhealthy housing or in struggling or insecure
neighborhoods. Such neighborhoods tend to have limited access to
medical care, nutritious groceries, and safe places to exercise and an
oversupply of fast foods, liquor stores, pollution, and crime.\5\ A
life of hardships is associated with higher rates of stress and
depression.\2\
The association between income and health applies to everyone, not
just those who are poor. Middle-class individuals have lower life
expectancy and worse health status than those who are wealthy.\4\ Rich
or poor, individuals facing more difficult financial circumstances tend
to defer clinical care and allow complications to linger. Disadvantaged
patients present to physicians in more advanced stages of disease that
are more difficult and costly to treat and are often less
survivable.\6\ In sum, budget policies that impose financial strain on
families or curtail educational opportunities could, in time, cause
greater morbidity, mortality, and costs--all of which are problematic
on moral and economic grounds.
The moral issue is clear: it is unsettling to adopt policies that
will induce a higher rate of premature deaths or greater disease or
disability. Such policies tend to disproportionately affect those who
are poor or who are members of racial or ethnic minority groups, and
they often affect children as well. These policies would be soundly
rejected if health outcomes and ethics were the only considerations,
but policymakers must also contend with economic and political
realities.
The core argument of fiscal conservatives is that difficult budget
decisions and fiscal discipline are necessary for the economy--a worthy
principle for many spending areas. However, fiscal discipline loses its
logic when spending reductions lead to greater illness and thereby
increase health care costs. Any policy that increases disease burden is
a threat to the economy because medical spending is so costly to
government and employers. Medicare, Medicaid, and children's health
insurance consume 23 percent of the Federal budget.\7\ Health care
costs are complicating efforts to balance State budgets, operate
businesses, and compete in the global marketplace. The need to control
medical cost inflation is a mounting national priority, one that argues
against budgetary policies that would increase morbidity, heighten
demand on the system, and drive up medical spending.
That unwanted scenario is a potential outcome of the more austere
budget cuts under current consideration, many of which would impose
economic strain on families, weaken support for education, and allow
neighborhood living conditions to become more unhealthy. The effect of
these conditions on health, relative to medical care, is often
underestimated. According to one estimate, giving every adult the
mortality rate of those who attend college would save seven times as
many lives as those saved by biomedical advances.\8\ It has been
estimated that 25 percent of all deaths in Virginia between 1990 and
2006 might not have occurred if the entire population had experienced
the mortality rate of those who lived in the State's most affluent
counties and cities.\9\
In the United States, the adverse socioeconomic conditions that are
linked with mortality have become more prevalent in the past decade,
especially with the economic recession. Between 2007 and 2009, median
household income decreased from $51,965 to $49,777, down from a peak of
$52,388 in 1999.\10\ Between 2000 and 2009, the number of households
with food insecurity increased from 10 million to 17 million.\10\ The
percentage of individuals with severe housing costs burdens (spending
more than 50 percent of their income on housing) increased from 13
percent in 2001 to more than 18 percent in 2009.\10\ The number of
homeless individuals in families requiring shelters or transitional
housing increased from 474,000 in 2007 to 535,000 in 2009.\10\ The
poverty rate increased from 11.3 percent in 2000 to 14.3 percent in
2009, its highest percentage since 1994 and the largest absolute number
on record.\10\
It is reasonable to predict that the population's exposure to these
conditions will eventually result in some increase in the prevalence
and severity of major illnesses, a trend that would place greater
demands on the health care system. Already, emergency departments and
hospitals are noting the recession's effect on admissions for
uncontrolled diabetes and heart failure. Lasting effects may take years
to document. Many of today's children could endure greater illness
decades hence and a shorter life expectancy because they grew up during
current conditions. This dismal forecast bears attention from health
care leaders, who must prepare capacity plans for the wave of patients
that a distressed economy would push into the system, and from
politicians and economists, who must consider how that care will be
financed by a system already too expensive to sustain.
Amid these conditions, it is fair to ask whether now is the right
time to cut programs that sustain living conditions for good health and
that protect U.S. residents from losing their jobs, income, education,
and food. The answer may be disappointing, as the downstream effects on
illness and spending may not be enough to outweigh the budgetary
pressures of the present, but the question should at least be posed and
the tradeoffs discussed. Too often, policymakers and the public fail to
recognize the connection between social and health policies, and this
seems true again as proponents and critics of current budget reforms
wage their debate. When policies could claim lives, exacerbate
illnesses, and worsen the economic crisis, these ramifications should
at least be discussed.
Note: Conflict of Interest Disclosures: The author has completed
and submitted the ICMJE Form for Disclosure of Potential Conflicts of
Interest and none were reported.
Note: Funding/Support: This Commentary cites research by the
Virginia Commonwealth University Center on Human Needs that was funded
by the Robert Wood Johnson Foundation (grant 63408) and the statistics
were compiled by the Center on Human Needs' Project on Societal
Distress, which is supported by the W.K. Kellogg Foundation (grants
P3008553, P3011306, and P3015544).
Note: Role of the Sponsor: The W.K. Kellogg Foundation and Robert
Wood Johnson Foundation had no role in the preparation, review, or
approval of the manuscript.
References
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2. Pleis JR, Lucas JW. Summary health statistics for U.S. adults:
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2010: With Special Feature on Death and Dying. Hyattsville, MD:
National Center for Health Statistics; 2011.
4. Braveman P, Egerter S. Overcoming Obstacles to Health: Report
From the Robert Wood Johnson Foundation to the Commission to Build a
Healthier America. Princeton, NJ: Robert Wood Johnson Foundation; 2008.
5. Miller WD, Pollack CE, Williams DR. Healthy homes and
communities: putting the pieces together. Am J Prev Med. 2011;40(1
suppl 1):S48-S57.
6. Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic
variation in U.S. cancer incidence, mortality, stage, treatment, and
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4. Bethesda, MD: National Cancer Institute; 2003. NIH publication 03-
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8. Woolf SH, Johnson RE, Phillips RL Jr, Philipsen M. Giving
everyone the health of the educated: an examination of whether social
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2007;97(4):679-83.
9. Woolf SH, Jones RM, Johnson RE, Phillips RL Jr, Oliver MN,
Vichare A. Avertable deaths in Virginia associated with areas of
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Accessed March 22, 2011.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Sanders. Thank you very much, Dr. Woolf.
Senator Warren, did you want to introduce Dr. Berkman?
Senator Warren. I do, Mr. Chairman. Thank you very much.
It is my honor to introduce Dr. Lisa Berkman, the Thomas
Cabot Professor of Public Policy and Epidemiology, and the
director of the Harvard Center for Population and Development
Studies at the Harvard School of Public Health. Dr. Berkman is
a social epidemiologist who examines the impact of social and
policy factors on health outcomes.
Dr. Berkman began her career at Northwestern University,
where she received her bachelor's in sociology, later attended
the University of California Berkeley where she earned both her
master's and her doctorate in epidemiology. Before joining the
faculty at Harvard, she spent 16 years as a professor at the
Yale School of Medicine.
Dr. Berkman's research, both in America and
internationally, has helped us better understand the role that
social inequality plays in people's health. She has authored or
co-authored 275 publications in peer-reviewed literature and
numerous book chapters, and is a member of the Institute of
Medicine.
I am so pleased that Dr. Berkman is with us here today, and
I am looking forward to an engaging conversation with her.
Senator Sanders. Dr. Berkman, thanks very much for being
here. Please begin.
STATEMENT OF LISA BERKMAN, Ph.D., DIRECTOR OF THE HARVARD
CENTER FOR POPULATION AND DEVELOPMENT STUDIES AND THOMAS D.
CABOT PROFESSOR OF PUBLIC POLICY AND EPIDEMIOLOGY, HARVARD
UNIVERSITY, CAMBRIDGE, MA
Ms. Berkman. Chairman Sanders, Senator Warren, Senator
Baldwin, and other members of the committee, thank you for this
invitation to testify. You have chosen a very provocative title
for this hearing. It calls for a straightforward response that
outlines more than the situation, but also includes potential
solutions.
First, I am going to describe, very briefly, trends in life
expectancy and the unequal distribution of lists of death by
socioeconomic status in the United States, then I will go to
some practical options for improving the Nation's health. I
will focus on work policy particularly here because it is an
area in which the Federal and State Governments have a role in
shaping policies that would reduce health disparities.
First, as we have said, U.S. life expectancy has lost
ground compared to other Nations in the last decades,
especially for women. I was a member of the National Academy of
Science's panel on longevity trends. It found that the United
States ranked at the bottom of 21 industrialized, developed
Nations. These low rankings are particularly striking for the
poor and for women.
Of most concern is the widening gap and the risk of death
between those at the bottom and those at the top. This gap has
widened over the past 25 years. For instance, in 2007, the
death rate for men without a high school education was 7 per
100; it was 2 per 100 for those with a college education. This
corresponds to a 3\1/2\-fold increased risk for those less-
educated men. This risk has grown substantially over the last
25 years.
Among women, the patterns are even more troubling. For
less-educated women, the risk of dying actually increased, as
you noted, in absolute terms during this time. Most striking,
this pattern holds even if we only look at white women in the
United States.
Now, using the public health framework, I want to show how
labor policies and practices can make a difference in
American's health. Although health insurance and access to
medical care can help reduce risks of financial catastrophe,
and also help cure disease once it occurs, healthcare alone
cannot prevent disease. It is like aspirin and headaches.
Aspirin can cure headaches, but headaches are not caused by
lack of aspirin; they are not aspirin deficiency diseases.
To reduce headaches, we need to focus on the cause of the
headache. For this same reason, we need to look at what causes
these high rates of dying among the poor and less-educated.
So turning to work, then. A number of studies on the
relationship between work and health show that employment
almost always associates with better health. These associations
last well into old age and relates to reduced mortality risk,
as well as to the maintenance of cognitive and physical
functioning.
Here are three specific work-related policies that promise
to improve health, especially for low wage earners and their
families. No. 1, the Earned Income Tax Credit program. EITC is
associated with improvement in infant health and decreases in
smoking among mothers. Getting the EITC means that your baby,
on average, will be 16 grams heavier. To put that in context,
it is equal to about one-third of the association between birth
weight and having a mother with a high school degree. EITC
reduces the odds of maternal smoking by 5 percent and increases
mother's odds of working and increases her wages.
No. 2, recent evidence on maternity leave policies in the
United States and Europe suggests that protecting employment
among expectant and recent mothers leads to better long-term
labor-market outcomes including wage level and growth, career
prospects, labor market attachment, and employability. Mounting
evidence suggests maternity leave is health-promoting for
infants and for their mothers throughout their lives.
No. 3, work-family practices. In a study that we did of
employees in long term care facilities--which is primarily a
low wage working group in a very highly regulated industry--we
found that when managers were attentive to work-family issues,
their employees were half as likely to have cardiovascular
risks compared to workers who have less family friendly bosses.
Specifically, these employees were less likely to be
overweight, they have lower blood pressure, lower diabetes.
The health effects that I have described here are not
counted in the current cost benefit metrics of these policies,
so we dramatically underestimate the real benefits that they
have. Our labor policies challenge working-class families to
remain simultaneously committed to work and to family. Over
half of low-wage earners lack sick leave to take care of
family. I could give you more policies that would help the
health of our low-income working families, but I will stop
here.
The EITC, pro-family work policies and practices, and
parental leave are just three examples of policies that impact
the health of low-income working families.
Thank you very much.
[The prepared statement of Ms. Berkman follows:]
Prepared Statement of Lisa F. Berkman, Ph.D.
Chairman Sanders, Senator Burr and members of the committee, thank
you for the invitation to testify.
I will discuss two issues today. First, I will describe trends in
U.S. life expectancy and the unequal distribution of mortality risk by
socioeconomic status in the United States. Second, I will elaborate on
options for improving the Nation's health, especially related to labor
policies for low-wage workers. I will frame our options for improving
health in terms of what we can do to create a healthy population and
prevent disease.
First, U.S. overall life expectancy--that is the expected number of
years someone born today can expect to live--has lost ground compared
to that of other nations in the last decades, especially for women. I
was a member of a recent National Academy of Science Panel on diverging
trends in longevity. It found that the United States ranked at the
bottom of 21 developed, industrialized nations \1\ and poor rankings
were particularly striking for women. In the 1980s our rankings were in
the middle of OECD countries in this study. While it is true that LE
improved during this time from by 5.6 years for men and 3.6 years for
women, other countries gained substantially more in terms of life
expectancy, leaving us behind. Furthermore, almost all those gains were
concentrated among the most socioeconomically advantaged segments of
the U.S. population. And they were more substantial for men than for
women. The poorest Americans experienced the greatest health
disadvantage compared to those in other countries.\2\ \3\ At a recent
NIH conference, the discussion was focused on the steps required for
the United States to reach just the OECD average in the next 20 years--
not even the top. It seems we have given up on achieving better than
average health.
More concerning is the widening gap in mortality--or risk of
death--between those at the bottom and at the top in the United States.
These gaps have widened over the last 25 years. These patterns are
evident whether we look at education, income or wealth differentials,
but because the evidence is clearest that education itself is causally
linked to health and functioning.\4\ \5\ I will focus on these
associations. For instance, the mortality for men with less than a high
school education in 2007, was about 7 per 100. For those with 16 years
or more of education, the rate was less than 2 per 100. This
corresponds to a 3\1/2\-fold risk of dying in 2007, compared to 2.5
times the risk in 1993. For less-educated women, their mortality risk
actually increased absolutely during this time giving rise to an
increased risk from 1.9 to 3 in 2007 \6\ and this pattern holds even if
we confine our analyses to white women.\7\ While it is true that fewer
adults are in the less-educated pool in later years, giving rise to
questions about selection issues, it is also true that adults in the
highest educated categories have grown over this same time suggesting
increased compositional heterogeneity in these groups. Overall while
selection into education level occurs, it accounts for only a small
part of this widening gap.
While mortality gaps in socioeconomic status have existed for
centuries, the magnitude of these differences has grown substantially
over time in the United States. These widening disparities suggest that
either disparities in the underlying determinants of illness and
mortality have also been growing over time or that support to buffer
these stressful conditions has changed. In either case, while we may
not be able to eliminate health disparities, the fact that the size of
the risks varies so much suggests that such large inequalities are not
inevitable or innate and, gives hope that there are ways to reduce the
burden of illness for our most vulnerable citizens.
Now, using a public health framework, I discuss the identification
of health risks. While health insurance and access to medical care help
reduce risks of financial catastrophe and can improve the health of
those suffering from illness, health care alone cannot ensure good
health and prevent the onset of disease. To illustrate this point, we
can think of the aspirin/headache analogy. ``While Aspirin cures a
headache, lack of aspirin is not the cause of headaches.'' Headaches
are not caused by aspirin deficiency--to reduce headaches we need to
focus on what causes headaches. This is what prevention and public
health approaches offer. Obviously it would be better to maintain
health than have to treat illness once it occurs. Treatments are
financially very costly, but more importantly, waiting to treat disease
is costly to the quality of lives of all Americans.
What would be required to produce better health among Americans and
reduce socioeconomic disparities in health? What do poor socioeconomic
conditions influence that could cause such increased risk across such a
huge number of diseases across all age groups from the infancy to old
age? You are all probably thinking about the usual suspects--smoking,
poor diet, and lack of exercise. I'm not going to focus on these usual
suspects today, not because I don't believe they pose substantial risks
to health, but because we know that it is very hard to change these
behaviors without considering the social and economic conditions that
shape them. These social and economic conditions are fundamental
determinants of health because they influence so many behaviors and
access to so many opportunities and resources. Change here will
influence a number of channels leading to increased mortality risk. In
my testimony I will focus on one of these conditions relating to
participation in the labor market.
Several years ago, I embarked on a study to assess the
relationships between employment, family dynamics and health. We found
that employment was almost always associated with better health. These
associations lasted well into old age.
Women who had the lowest mortality risk in later adulthood had
spent some time out of the labor market (a few years over the career
path) but maintain steady labor force participation for most of their
lives until retirement. Drawing on data from the Health and Retirement
Study, we find that among married mothers, those who never worked had
an age-standardized mortality rate of 52.\6\ whereas mothers who took
some time off when their children were young but who later joined the
workforce and mortality rates of around 40. Single mothers who never
worked had the highest mortality of 98 compared to 68 for single
mothers who worked.
Selection into the labor force may account for some of this
association, but more experimental evidence confirms the positive
health benefits of working especially for low-income women and men.
For example, the EITC is associated with improvements in infant
health and decreases in smoking among mothers.\8\ In an analysis of
State variation in the Earned Income Tax Credits (EITCs) between 1980
and 2002, Strully finds that EITC's increase birth weights by, on
average, 16 grams. To put that in context, it is equal to about a third
of the association between birth weight and having a mother with a high
school degree. Living in State with EITC reduces the odds of maternal
smoking by 5 percent, and increases mother's odds of working and
increases her wages and salary.
Recent evidence from several studies of maternity leave policies in
the United States and Europe suggests that, by protecting employment
among mothers in the period around birth, maternity leave leads to
better long-term labor market outcomes after maternity including wage
level and growth, career prospects, labor market attachment and
employability.\9\ \10\ \11\ \12\ Thus not only may maternity leave
benefit children and mothers around the period of birth, they may have
long-term benefits for mothers that extend for decades in later
adulthood.
In an observational study of employees in long-term care
facilities, we found that workers whose managers were attentive to
work-family issues had half the cardiovascular risks as assessed by
objective biomarkers from blood or clinical exam and healthier patterns
of sleep compared to those who worked for less family-friendly
managers.\13\ Specifically, employees whose managers maintained family-
friendly practices were less likely to be overweight, had lower risk of
diabetes and lower blood pressure. Based on objective measures of sleep
using actigraphy monitors, these same employees slept almost 30 minutes
more per night than their counterparts. For nurses and certified
nursing assistants in low- and middle-wage jobs, these are important
risks to which they were exposed.
Such research suggests that labor policies and practices that
support men and women in the labor force and especially help those with
caregiving obligations are health promoting. These policies and
practices have health effects that are not often ``counted'' as we
think about their costs and benefits. Men and women will need
opportunities and flexibility and schedule control to enter and remain
in the labor force given the inevitability of having to care for
children, parents, or partners at some point in time. Our goal for
women should be to enable them to be successful in their productive as
well as reproductive lives. Right now, we make this very difficult. Our
labor policies challenge working class families to remain committed to
work and to their families. For example, over half (54 percent) of low-
wage earners lack sick leave or vacation to take care of families and
around 30 percent of middle-income families lack such leave.\14\ Even
fewer have parental leave.
We have shown that we can identify the socioeconomic disparities in
health with some precision. Solutions that help to maintain low- and
working-class men and women in the paid labor force have clear health
benefits. The EITC, pro-family work policies and practices and parental
leave are examples of polices that impact health of low-income working
families. Targets enabling adults to participate in the paid labor
force while not risking the health and well-being of their family
members show particular value. Metrics for evaluating social and
economic policies do not currently include health metrics. The health
spillovers of such policies would increase the benefits of such
policies in any cost-benefit equations. We want to ensure that
Americans, particularly those living in poverty and working-class
families aren't robbed of healthy years of life.
References
1. National Research Council (US) Panel on Understanding Divergent
Trends in Longevity in High-Income Countries; Crimmins EM, Preston SH,
Cohen B, editors. Explaining Divergent Levels of Longevity in High-
Income Countries. Washington (DC): National Academies Press (US); 2011.
Available from: http://www.ncbi.nlm.nih.gov/books/NBK62369/.
2. Avendano M, Glymour MM, Banks J, Mackenbach JP. Health
disadvantage in U.S. adults aged 50 to 74 years: a comparison of the
health of rich and poor Americans with that of Europeans. Am J Public
Health. 2009 Mar;99(3):540-8. doi: 10.2105/AJPH.2008.139469. Epub 2009
Jan 15. PubMed PMID: 19150903; PubMed Central PMCID: PMC2661456.
3. Banks J, Marmot M, Oldfield Z, Smith JP. Disease and
disadvantage in the United States and in England. JAMA. 2006 May
3;295(17):2037-45. PubMed PMID: 16670412.
4. Lleras-Muney, Adriana. ``The Relationships Between Education And
Adult Mortality In The United States,'' Review of Economic Studies,
2005, v72(250,Jan), 189-221.
5. Glymour MM, Kawachi I, Jencks CS, Berkman LF. Does childhood
schooling affect old-age memory or mental status? Using State schooling
laws as natural experiments. J Epidemiol Community Health. 2008
Jun;62(6):532-7. doi: 10.1136/jech.2006.059469. PubMed PMID: 18477752;
PubMed Central PMCID: PMC2796854.
6. Ma J, Xu J, Anderson RN, Jemal A (2012) Widening Educational
Disparities in Premature Death Rates in Twenty Six States in the United
States, 1993-2007. PLoS ONE 7(7): e41560. doi:10.1371/
journal.pone.0041560.
7. Montez JK, Hummer RA, Hayward MD, Woo H, Rogers RG. Trends in
the Educational Gradient of U.S. Adult Mortality from 1986 to 2006 by
Race, Gender, and Age Group. Res Aging. 2011 Mar;33(2):145-171. PubMed
PMID: 21897495; PubMed Central PMCID: PMC3166515.
8. Strully KW, Rehkopf DH, Xuan Z. Effects of Prenatal Poverty on
Infant Health:State Earned Income Tax Credits and Birth Weight. Am
Sociol Rev. 2010 Aug 11;75(4):534-562. PubMed PMID: 21643514; PubMed
Central PMCID: PMC3104729.
9. Brugiavini, A., Pasini, G. and E. Trevisan (2013) ``The direct
impact of maternity benefits on leave taking: evidence from complete
fertility histories'', Advances in life course research, 18: 46-67.
10. Rossin M. The effects of maternity leave on children's birth
and infant health outcomes in the United States. J Health Econ. 2011
Mar;30(2):221-39. doi: 10.1016/j.jhealeco.2011.01.005. Epub 2011 Jan
18. PubMed PMID: 21300415; PubMed Central PMCID: PMC3698961.
11. Rossin-Slater M, Ruhm CJ, Waldfogel J. The effects of
California's paid family leave program on mothers' leave-taking and
subsequent labor market outcomes. J Policy Anal Manage. 2013;32(2):224-
45. PubMed PMID: 23547324; PubMed Central PMCID: PMC3701456.
12. Ruhm CJ. Policies to assist parents with young children. Future
Child. 2011 Fall;21(2):37-68. PubMed PMID: 22013628; PubMed Central
PMCID: PMC3202345.
13. Berkman LF, Buxton O, Ertel K, Okechukwu C. Managers' practices
related to work-family balance predict employee cardiovascular risk and
sleep duration in extended care settings. J Occup Health Psychol. 2010
Jul;15(3):316-29. doi: 10.1037/a0019721. PubMed PMID: 20604637; PubMed
Central PMCID: PMC3526833.
14. Heymann SJ. The Widening Gap: Why Working Families Are in
Jeopardy and What Can Be Done About It. New York: Basic Books, 2000.
Senator Sanders. Thank you very much, Dr. Berkman.
Senator Burr is unable to be with us this morning, but his
guest is Dr. Nicholas Eberstadt, who is the Henry Wendt Chair
in Political Economy at the American Enterprise Institute. He
is also a senior advisor to the National Bureau of Asian
Research, a member of the Visiting Committee at the Harvard
School of Public Health, and a member of the Global Leadership
Council at the World Economic Forum. He researches and writes
extensively on economic development, foreign aid, global
health, demographics, and poverty.
Dr. Eberstadt, thanks very much for being with us.
STATEMENT OF NICHOLAS EBERSTADT, Ph.D., MPA, M.Sc., HENRY WENDT
CHAIR IN POLITICAL ECONOMY, AMERICAN ENTERPRISE INSTITUTE,
WASHINGTON, DC
Mr. Eberstadt. Mr. Chairman, Senators Warren, Baldwin,
distinguished co-panelists, and guests.
It is an honor to be here. My testimony focuses upon the
exceptions to the established generalization that better
education, better health access, and better income result in
better health outcomes. Nobody disputes this, but the
predictive power of those generalizations should be
appreciated, because it is limited.
In my testimony, I show a number of tables which make this
argument more clearly than perhaps one can in a brief period of
time. If we look at Table 1 in my testimony, I show poverty
rates, percentages of adults without high school degrees, GINI
coefficients, percentages with no health insurance, and age-
adjusted percentages of adults 18 or over with no healthcare
visits in the previous 12 months for non-Hispanic whites, also
known as Anglos, for Asian Pacific Americans, for Black non-
Hispanic African-Americans, for Hispanics, and for the country
as a whole.
Now what you will see in this chart is that by all of these
indicators, by far the most advantaged group in the United
States are the Anglos, lower poverty rates, lower percentages
of adults without high school education, lower GINI
coefficients for family income, lower percentages without
health insurance, and lower percentages who have never been to
a doctor or another professional in the last 12 months.
One would think on the basis of what we know that these
Anglos would have better than average mortality for the United
States as a whole. They do not. In fact, their mortality level,
age standardized, is slightly worse than the Nation as a whole.
If one takes a look at the group which seems to be most
disadvantaged by these metrics, which would be Latinos, their
age standardized mortality is not higher than the national
average. In fact, it is 25 percent lower. We should want to
understand why this paradox occurs.
If we look at Figure 5 in my testimony, which shows life
expectancy in the County of Los Angeles, America's largest,
most populous county, the most privileged group in terms of
poverty rate would be the non-Hispanic whites. Latinos have a
poverty rate which is over twice as high as the Anglos in Los
Angeles County, yet the life expectancy at birth for Latinos in
Las Angeles is almost 2\1/2\ years higher than for whites. We
should want to understand how this sort of an outcome can
occur.
In Figure 8 in my testimony, I use an analysis, or I
present an analysis, done by the New York City Department of
Health which shows life expectancy by ethnicity and by poverty
statuses, neighborhoods. One of the fascinating results here,
for Asian-Americans, the poverty status of neighborhoods makes
practically no difference in life expectancy, and life
expectancy for Asian-Americans in New York City is higher than
for any other group. We should want to know how that can be.
Finally, Figures 11 and 12, I take estimates made by the
Social Science Research Council in New York City for life
expectancy by ethnicity by State across the United States, and
I compare these with life expectancy as estimated by the U.S.
Census Bureau for various OECD countries.
You can see in Figure 11 that for Hispanic Americans taken
by themselves, life expectancy at birth is higher than for any
OECD country. The healthiest country in the world at this point
is Japan. Latino life expectancy in America is higher than life
expectancy in Japan. And the figures for Asian-Americans are
just off the charts.
If the United States was a nation of only Latinos and
Asian-Americans, disadvantaged groups by these indicators I
used, we would be the healthiest country on earth.
A question for us, it seems to me, a critical question is:
how do some disadvantaged groups achieve excellent, world-class
health outcomes? If we answer that question, I think we can
help to increase health for all Americans.
Thank you.
[The prepared statement of Mr. Eberstadt follows:]
Prepared Statement of Nicholas Eberstadt, Ph.D., MPA, M.Sc.
Mr. Chairman, distinguished Members, esteemed co-panelists and
guests, in these august chambers, as in other policymaking circles in
Washington and around the Nation, a policy syllogism is gaining
currency and receiving increasingly respectful attention. The syllogism
runs something like this: health progress is faltering in America
today; faltering health progress is the consequence of social and
economic disparities; therefore government must intervene to reduce
disparities if health progress is to be revitalized.
Influential as this syllogism has come to be nowadays, I submit
that it is empirically flawed, and therefore requires serious
qualification and re-examination.
The problem with the syllogism lies not in its assertion that
health progress in modern America is disappointing. For the Nation as a
whole, the evidence to this effect is, unfortunately, overwhelming.
Rather, the trouble lies with the proposition that social and
economic disparities are the cause of America's disappointing health
performance today.
To be clear: this is not to ignore the great corpus of data
pointing to a widening of income differences and other economic
differences in America over the past generation. Nor is it to suggest
that it is not better to be affluent, educated, and well-insured.
Obviously it is: and not just for reasons bearing on health.
Yet the perhaps curious fact of the matter is that real existing
social and economic disparities are just not that good in predicting
real existing health disparities in our real existing modern America.
In fact, it is commonplace today for poorer, less-educated groups to
enjoy substantially *better* health outcomes than those who would
appear to enjoy distinctly greater socioeconomic advantages. The
surprising--but also hopeful--fact is that it is possible for groups
suffering what might be described as both social and economic
disadvantage to achieve very good health outcomes in America today. And
that is not just a technical, arcane, theoretical possibility: it is a
main street reality, ratified by the survival profiles of millions upon
millions of Americans today.
We manifestly need to understand exactly how it is that so many
Americans today manage to achieve good or excellent health outcomes
with limited incomes, educational backgrounds, and other socioeconomic
resources. But manifestly, the mental straitjacket that the ``social
disparities'' mindset imposes on public health research is incapable of
helping us in this critical task.
The tables and graphs that accompany this written statement offer
data and analysis that underscore, and expand upon, the summary points
offered telegraphically in the preceding paragraphs.
Let us begin with the question of America's health record over the
postwar era. There is really no question at this point as to the at-
best mediocre results we as a society have garnered over the past half
century and more. While our country has achieved continuing incremental
improvements in overall health conditions (as reflected in the mirror
of mortality), our progress has been decidedly slower than in other
affluent Western democracies--and thus our ranking in this roster has
gradually but steadily declined.
We can see this in Figures 1 and 2 of the attachment to this
written statement. [See Figures 1 and 2] The graphics trace out the
trends in years of combined male and female life expectancy at birth on
the one hand, and infant mortality rates per thousand live births on
the other hand, for the United States and 23 other never-communist
members of the OECD (Organization for Economic Cooperation and
Development), an association of aid-dispensing Western industrialized
democracies.
These estimates come from the Human Mortality Data base, a project
undertaken by the University of California at Berkeley and the Max
Planck Institute for Demographic Research in Germany--since experts in
this network have carefully examined the underlying data from all these
countries and offered their own corrections or reconstructions as
warranted, we get an ``apples to apples'' comparison here.
As can be seen in Figures 1 and 2, despite continuing progress in
reducing mortality levels, America has gone from a more or less
middling ranking in this pack of 24 countries shortly after the end of
World War II (1950) to the very poorest ranking among these 24
countries today (circa 2010). Life expectancy at birth is now estimated
by the Human Mortality Database researchers to be lower in the USA than
in any of the other 23 comparators--and infant mortality conversely is
placed highest in the USA for any country in this same group. Trend
lines for the odds of surviving from birth to say age 65, or any other
measure for the risk of premature mortality, would tell a roughly
similar story for America's health performance over the postwar era.
What accounts for this long-term relative decline in U.S. health
performance?
Over the past half century, America has become an increasingly
multiethnic society, and it has also seen the emergence of growing
economic differences. (Admittedly, rising measured economic differences
have also been characteristic of almost all other affluent Western
democracies over these same decades--but measured income dispersion in
the USA today appears to be greater than in almost all of the
comparator countries in Figures 1 and 2).
It is tempting to link these big changes in American society and
economy with our disappointing health performance. This impulse,
indeed, is at the heart of the current popularity of the ``social
disparities'' paradigm, so widely utilized in public health research on
America today. There is no gainsaying the general insight that more
prosperous and better-educated people should be expected to have more
favorable health outcomes than those who are less well-to-do. But as a
practical matter, socioeconomic disparities do not seem to offer us all
that much help in understanding the big health differentials we see in
our society today.
Table 1 makes the point. [See Table 1] It presents figures for
America's major ethnic groups on the one hand for major indices of
social and economic disparity--poverty rates; proportions of the adult
population without high school education; income distribution for
families; percentages of persons without health insurance; percentages
of adults with no health care visits over the previous 12 months--and
on the other for age-standardized mortality.
If the ``social disparities'' model has much predictive power in
the modern American context, we would expect these major disparities to
track with differential in mortality. We should bear this in mind when
we examine the findings in Table 1.
Consider what this table reveals for the ``non-Hispanic White''
(i.e., ``Anglo'') population in contemporary America (i.e., around the
year 2010). By all indicators in this table--poverty, education, income
distribution, access to health insurance, use of health services in the
past 12 months--the ``Anglo'' community or population appears to be
decidedly better off on average than Americans as a whole. But age
standardized mortality for Anglos is no better than for the U.S.A. as a
whole. Indeed, age standardized mortality is reportedly slightly
*higher* for Anglos than for the Nation as a whole.
Needless to say, if social and economic disparities were the
dominant factor in determining health outcomes in the United States,
the improbable correspondence between relative socioeconomic privilege
and slightly less-than-average health results for Anglo America today
would be unfathomable. But the situation is even more striking than
this one comparison would suggest.
Consider next the circumstances for our Asian minority (officially,
Asian and Pacific Islanders). On all of the social and economic
indicators in Table 1, the Asian population fares less favorably than
the Anglos. Yet age-standardized mortality levels for our Asian-Pacific
population are officially estimated to be over 40 percent below the
national average.
Finally, consider the situation for the Hispanic population in
America today. By a number of measures, it would appear to be *the*
most socioeconomically disadvantaged major ethnic group in America
today. Nearly 40 percent of Hispanic American adults, for example, have
no high school degree (2009); over 30 percent of all have no health
insurance (2010); and nearly 30 percent of Hispanic adults did not
report even a single visit to get health care over the previous year
(2010). Even so: the age-standardized mortality level for Hispanic
Americans is estimated to be fully 25 percent lower than the average
for the Nation as a whole!
Thus the striking paradox of health in modern America is this:
minority groups reporting higher incidences of poverty and income
inequality, lower educational attainment, less health insurance
coverage, and greater likelihood of no treatment by medical
professionals than our Anglo majority also report significantly lower
mortality (and thus longer life expectancy) than our Anglos--indeed,
significantly better mortality levels than for America as a whole. And
this paradox is not new: as Figures 3 and 4 attest, for males and
females alike, mortality rates for our Asian and Hispanic minorities
have been superior to those of non-Hispanic Whites for many decades--in
fact, for as long as such numbers have been compiled. Non-Hispanic
Blacks or African-Americans are the only ethnic minority whose health
profile appears to be poorer nowadays than our Anglos.
The phenomenon of superior health performance by ostensibly
disadvantaged minorities can be seen from sea to shining sea. Consider
first Los Angeles County: with nearly 10 million inhabitants, the
Nation's most populous jurisdiction, fewer than 30 percent of whose
residents are Anglos. [See Figure 5] According to the LA County
Department of Public Health, total male and female life expectancy at
birth for these non-Hispanic White residents in 2010 was actually a bit
below the countywide average (80.8 years vs. 81.5 years). But the
official poverty rate for the Anglo population in LA County is well
below the countrywide average. On the other hand, Hispanics and Asians
both suffered higher poverty rates than Anglos--the rate for Latinos
was over twice as high as for non-Hispanic Whites--yet their life
expectancies were also markedly higher. In 2010, the Latino edge in
life expectancy over Anglos in LA County amounted to roughly 2.4 years;
for Asians, the premium was fully 5 years. Is ``your social and
economic status'' a ``death sentence in America,'' as the title of our
hearing today avers? Evidently, not in Los Angeles.
Now consider New York City, the Nation's biggest urban
jurisdiction. [See Figure 6] As we all know, the ``Hispanic''
designation encompasses a wide variety of backgrounds. In terms of
country or place of origin, the Latino population of New York City is
quite different from Los Angeles County. No matter: according to the
New York Department of Health, Hispanics still edge out Whites in life
expectancy in New York City, and have been doing so for many years,
even though the Hispanic population's poverty rate in 2010 was over
twice as high as the rate for Whites.
If we look at age-standardized mortality in New York City, we see
our national health paradox instantiated locally. [See Figure 7] Here
again, mortality levels are lower for Hispanics and for Asians than for
Whites, even though their official poverty rates are higher. It is true
that mortality levels for New York's Black population is dramatically
higher than for its White population--and poverty rates for Blacks in
New York were about twice as high as for non-Hispanic Whites in the
period under consideration. But the Hispanic poverty rate in New York
was very appreciably higher than the Black rate, even as the Hispanic
age-adjusted mortality levels were fully one-third lower than Black
levels.
In and of itself, poverty just isn't that good a predictor of
health outcomes in New York City. That point is further emphasized in
an analysis by the New York City Department of Health on life
expectancy, ethnicity, and neighborhoods. [See Figure 8] It is true
that the very lowest life expectancy was recorded for Black New Yorkers
who lived in the city's poorest neighborhoods. It is also true that
life expectancy generally tended to increase for city residents as the
affluence of their neighborhood increased. So far, so good for the
``social disparity'' model. But the biggest differences in health
outcome in New York City just can't be predicted by this proxy of
affluence or disadvantage. Note that life expectancy for African-
Americans in the city's most affluent neighborhoods was notably lower
than for Hispanics in the city's poorest neighborhoods. Note as well
that there was no ``poverty neighborhood'' effect whatsoever for New
York's Asian population. Indeed: according to this analysis, the very
healthiest group in New York City was Asians who lived in New York's
poorest neighborhoods. These people enjoyed life expectancies roughly 5
years higher than for Whites from the city's wealthiest neighborhoods.
Let us return to our international comparison of America's health
performance. The disappointing picture painted in Figure 1 turns out to
be much more interesting, and somewhat more promising, when we
disaggregate life expectancy by State and by ethnicity. We can do so
with the aid of research by the ``Measure of America'' project from the
Social Science Research Council (SSRC), which permits us to compare
State-level life expectancy at birth by ethnicity with U.S. Census
Bureau estimates for life expectancy at birth for the rest of the OECD.
[See Figures 9-12] As we can see, America's international health
standing depends very much on which group and region we are talking
about.
For African-Americans, the story is pretty dispiriting--the
nationwide average for life expectancy for American Blacks is lower
than the life expectancy of all but three of the OECD's 34 countries,
and even the highest calculated State-level African-American life
expectancy (Rhode Island) is lower than 20 of the OECD's country-level
averages.
For U.S. Whites, the situation looks better, but only to a degree.
By these SSRC calculations, the nationwide life expectancy at birth for
America's Whites ranks below the life expectancy at birth of fully 20
OECD countries, as estimated by the U.S. Census Bureau. The dispersion
of life expectancy by State for America's Whites is noteworthy. Among
U.S. Whites, life expectancy for the longest living region (Washington
DC) is higher than for any country in the OECD--but life expectancy for
the lowest region (West Virginia) is worse than for all but four OECD
nations.
When we place Hispanic America's health in international
perspective, the contrast is dramatic. To many viewers, the results are
likely to be unexpected. By themselves, Hispanic Americans today are
estimated to enjoy a life expectancy higher than for any country in the
OECD--higher even than Japan, the world's healthiest society by the
yardstick of life expectancy.
And America's Asian population is almost off the chart. By the
SSRC's reckoning, Asian Americans nationwide can expect to live about 5
years longer than citizens of Japan; life expectancy for Asian
Americans in their lowest-health State (Hawaii) would be a bit higher
than life expectancy in Switzerland; and in at least six States. Asian-
American life expectancy at birth nowadays is placed above 90 years.
Viewed from this perspective, America's health problem looks a
little different from the conventional formulations. If the United
States were a nation composed solely of its Hispanic and Asian Pacific
minorities--populations, as we have seen, where conventionally
described ``social disparities'' weigh heavier than on the Nation as a
whole--we would be the healthiest country on earth. Our nationwide
health problem is a problem within our African-American population--a
group that suffers disproportionately from poverty and other
conventional metrics of socioeconomic disadvantage--and our Anglo
population--a group that suffers *less* from poverty and other
conventional metric of socioeconomic disadvantage than the Nation as a
whole.
As should by now be apparent, health outcomes in modern America are
a consequence of something beyond abstract social forces. Seeming
victims of ``social disparities'' regularly achieve high levels of life
expectancy--very often, levels better than those with seemingly greater
social and economic advantages. If we are truly interested in improving
our country's public health conditions, we should be asking what is
going *right* in these populations and these communities. Is it
behavior? Lifestyles? Outlook and attitudes? Some combination of these
things? We should desperately want to know. We will not--indeed
cannot--learn the answers to this critically important question to our
Nation's well-being if we insist on attempting to protect the
conclusion that social inequality is really what ails us.
______
Attachments--Tables and Figures
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Sanders. Thank you very much.
Senator Baldwin, did you want to introduce Dr. Kindig?
Statement of Senator Baldwin
Senator Baldwin. I would be honored. Thank you, Mr.
Chairman.
I want to thank you and Ranking Member Burr for convening
this hearing. We all know of your longstanding commitment to
issues of income inequality, poverty, and health disparities.
Too often, these issues are not discussed; they are swept under
the rug. We know as a Nation, we have to do better to make sure
that every American has a fair shake and a fair shot at
success. Thank you, Mr. Chairman.
You have invited a distinguished panel here today,
including a star from my home State of Wisconsin. Dr. David
Kindig is Emeritus Professor of Population Health Sciences and
Emeritus Life Chancellor for Health Sciences at the University
of Wisconsin Madison School of Medicine. He co-directs the
Wisconsin site of the Robert Wood Johnson Health & Society
Scholars Program. He also serves as editor for the Improving
Population Health blog.
Dr. Kindig served as senior advisor to Donna Shalala,
Secretary of Health and Human Services, from 1993 to 1995. In
1996, he was elected to the Institute of Medicine National
Academy of Sciences. He chaired the Institute of Medicine's
Committee on Health Literacy in 2002 to 2004, as well as
Wisconsin Governor Jim Doyle's Healthy Wisconsin Task force in
2006. In 2007, he received the Wisconsin Public Health
Association's Distinguished Service to Public Health Award.
Dr. Kindig.
STATEMENT OF DAVID A. KINDIG, M.D., Ph.D., EMERITUS PROFESSOR
OF POPULATION HEALTH SCIENCES, UNIVERSITY OF WISCONSIN SCHOOL
OF MEDICINE AND PUBLIC HEALTH, MADISON, WI
Dr. Kindig. Thank you very much, Senator Sanders, Senator
Warren, and Senator Baldwin for that really warm introduction.
Great to see you here in this role.
I thank you all for the opportunity to speak today about
the social and economic factors that have caused many Americans
to have shorter and less healthy lives than the generations
that have gone before them. I have worked my whole career in
what we now call population health, beginning as a pediatric
resident in a poverty neighborhood in the South Bronx and
serving as the first Medical Director of the National Health
Service Corps in 1971.
This hearing shines light on something that many people do
not yet understand: that while healthcare is necessary for
health, it is not the only, nor even the most, important factor
in producing longer, healthier, and more productive lives.
Health is produced by many factors including medical care and
health behaviors, but equally importantly or more importantly,
issues like income, education, the structure of our
neighborhoods, as my colleagues have been showing.
The bottom line is we will not improve our poor health
performance unless we balance our financial and policy
investment across this whole portfolio of factors.
For many years, I ran the Population Health Institute at
the University of Wisconsin School of Medicine and Public
Health. With my colleagues, we created the County Health
Rankings for use in Wisconsin prior to collaborating with the
Robert Wood Johnson Foundation to take the rankings national.
An easy to use snapshot, the rankings compare counties on a
range of factors, as I have mentioned, particularly including
the social factors on employment and income. In fact, we weight
those factors in the rankings model as 40 percent of what
impacts our health outcomes.
We initially did this for 6 years in Wisconsin for only our
72 counties. I will never forget the first morning we released
those first rankings. I got a call from a radio talk show in a
rural Wisconsin town; I believe it was Platteville. The first
question asked was, this is like 7:30 a.m., ``Dr. Kindig, does
this report mean that income levels in our county is as
important as the number of persons with health insurance? '' I
was surprised, but I could not have been more gratified to get
that kind of a call to begin that program.
I encourage each of you to take a look at the rankings in
your State and see the factors which impact the health of those
counties.
The last several decades have shown a growing awareness of
such a broad perspective, work like Lisa's and Steve's and
others. Currently, I am co-chair of a new Institute of Medicine
Roundtable on Population Health Improvement, just started 6
months ago. The vision of that roundtable starts, outcome such
as improved life expectancy, quality of life, and health for
all are shaped by interdependent, social, economic behavior
factors and will require robust national and community-based
actions and dependable resources to achieve it.
In my testimony, I listed several studies that we have done
on this matter, I'll highlight two orally. One showed a
fourfold variation in county death rates substantially
influenced by median-family income level. An $8,900 increase in
median-family income was associated with an 18 percent
reduction in death rates in low-income counties and 12 percent
in high-income counties.
Another study that the Chairman referred to, which is the
map before you, showed this shocking, actually, increase in
female mortality rates across the United States. The most
important factors associated with this were college education,
smoking, and median household income.
We know now that much more than healthcare is needed. Even
though, of course, everyone needs access to affordable, quality
care. Evidence for investments in efforts like early childhood
education and many prevention programs, there is good, strong
evidence for that, and that is beginning to result in new
investments in many American communities.
But in a time of limited resources, we still need more
efforts from private foundations and the Federal Government to
much more aggressively fund the kind of studies that will help
us to determine the most cost-effective investment and policy
choices across these multiple determinants for a healthier
future so we can make the right balance of investments.
We do know enough to act now, however. I am not just
advocating research. As a former pediatrician, it just pains me
that many children born today in poverty will have shorter and
unhealthier lives determined in the next few years, by the time
they get to middle school. That will impact those maps as we go
forward.
I have been looking at these maps for my entire career and
I am, frankly, very tired of it. At a time when the important
issue of medical care access and cost is front page news every
day, I commend this committee for bringing attention to the
other determinants of health, which are at least as important
in changing the color of these maps.
It is time for these maps to change.
Thank you very much.
[The prepared statement of Dr. Kindig follows:]
Prepared Statement of David A. Kindig, M.D., Ph.D.
Thank you Chairman Sanders and Ranking Member Burr for the
opportunity to speak today about the social and economic factors that
have caused many Americans to have shorter and less healthy lives than
the generations that have gone before them.
My name is David Kindig, and I am Emeritus Professor of Population
Health Sciences at the University of Wisconsin School of Medicine and
Public Health. I have worked my whole career in what we now call
population health, beginning as a pediatric resident in an Office of
Economic Opportunity Neighborhood Health Center in the South Bronx and
serving as the first Medical Director of the National Health Service
Corps in 1971.
This hearing shines needed light on something that many citizens
and policymakers don't yet understand . . . that while health CARE is
necessary for health, it is not the only or even the most important
factor in producing longer life and lives of high quality and
productivity. As my colleagues have already pointed out, modern
epidemiology and social science have established that health is
produced by many factors including medical care and health behaviors
and, importantly, components of the social and physical environment in
which we live in like income, education, social support, and the
structure of our neighborhoods. The bottom line is that we will not
improve our poor performance unless we balance our financial and policy
investments across this whole portfolio of factors.
For many years I ran the Population Health Institute at the
University of Wisconsin School of Medicine and Public Health, and with
my colleagues created the initial County Health Rankings
www.countyhealthrankings.org. An easy-to-use snapshot, the rankings
look at the overall health of nearly every county in all States. They
compare counties on a range of factors that influence health such as
tobacco use, physical inactivity, and access to health care, and more
importantly, social and economic factors, including education,
employment and income. In fact, these latter factors are assigned the
largest weight at 40 percent. (www.countyhealthrankings
.org/our-approach).
We initially did this for 7 years for only the 72 Wisconsin
counties. I will never forget the morning of the first Wisconsin
release, I got a call from an early morning radio talk show in rural
Wisconsin and the first question asked was ``Dr. Kindig, does this
report mean that the income level in our county is as important as the
number of persons with health insurance?'' I could not have dreamed of
a better and more sophisticated question to begin this program. I
answered that this was certainly the case although we don't know for
sure the exact balance in every county since all places vary in both
their health outcomes and the factors producing those outcomes. Today
this same model is used all across the country in the national County
Health Rankings and Roadmaps program, and many communities are using it
to prioritize health needs and solutions across their community. In
early 2013, six communities were awarded the initial RWJF Roadmaps to
Health Prize; to be eligible they had to show excellence in all the
determinants including social and economic factors. The initial six
Prizes were awarded to two communities in Massachusetts and one each in
California, Louisiana, Michigan, and Minnesota. (http://
www.countyhealthrankings.org/roadmaps/prize/about-prize).
As my colleagues here have indicated, the last several decades have
shown a growing awareness of such a broad perspective. Currently, I am
co-chair of a new Institute of Medicine Roundtable on Population Health
Improvement, whose vision states in part,
``Outcomes such as improved life expectancy, quality of life,
and health for all are shaped by interdependent social,
economic, environmental, genetic, behavioral, and health care
factors, and will require robust national and community-based
actions and dependable resources to achieve it . . . the
roundtable will therefore facilitate sustainable collaborative
action by a community of science-informed leaders in public
health, health care, business, education and early childhood
development, housing, agriculture, transportation, economic
development and non-profit and faith-based organization.''
I will briefly mention a few of the studies my colleagues and I
have conducted on this topic. The first of two I did with my graduate
student Erika Cheng in which we showed a fourfold variation in county
death rates substantially influenced by median-family income level.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
An $8,900 increase in median-family income was associated with an
18 percent reduction in death rates in low-income counties and 12
percent in high-income counties.
In the second study, shown on the map before you, we examined the
change in mortality rates across U.S. counties over the past decade,
and showed surprisingly that mortality rates for females had actually
worsened in 42 percent of counties, those shown in the shaded area,
primarily in the south and west regions.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We found several factors associated with this worsening, the most
important being college education, smoking, and median-household
income. In this study no medical care factors such as percent uninsured
or number of primary care physicians were associated with this
worsening over time.
We also examined, ``How Healthy Could a State Be?'', in which we
modeled how State mortality rates could improve if they each had the
highest level of all the determinants that any State had already
achieved.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We found that even the healthiest State, New Hampshire, could
improve mortality by 24 percent and the least healthy, West Virginia by
46 percent. The factors most associated with this improvement were
reducing smoking rates, increasing insurance, increasing high school
and college graduation rates, increasing median-family income, and
increasing employment.
So we know that much more than health care is needed, even though
of course, everyone needs access to affordable quality care. Evidence
for investments in efforts like early childhood education is strong,
resulting in such new investments in many communities. An Institute of
Medicine committee on Health Literacy that I chaired (A Prescription to
End Confusion) found that 40 percent of American adults do not have
adequate literacy skills to effectively navigate the health care
system. But in a time of limited resources we do not know enough to
guide exact choices of the most cost-effective investment balance
across all determinants in a given community. This is why my colleague,
John Mullahy, and I published a commentary in JAMA titled,
``Comparative Effectiveness of What: Evaluation Strategies for
Improving Population Health'' (2010, 304 (8):901-2) in which we argued
that now that we are realizing that social factors play such an
important role in health outcomes, we need private foundations and the
Federal Government to much more aggressively fund the kind of studies
beyond medical care alone that will help us make the best investment
and policy choices across the social determinants for a healthier
future.
But we know enough to act now. Many children born in poverty will
have shorter and unhealthier lives determined by the time they get to
middle school. I have been looking at these maps for my entire career
and am frankly very tired of it. At a time when the important issue of
medical care access and cost is front page news every day, I commend
this committee for bringing attention to the other determinants of
health which are at least as important in changing the color of these
maps.
Thank you for the invitation to appear before you today to discuss
these important issues. I look forward to your questions.
Senator Sanders. Dr. Kindig, thank you very much.
Our next panelist is Sabrina Shrader, who grew up in
McDowell County, WV, and that is a county in our country with
one of the lowest life expectancies. I believe it is the lowest
for men, and the second lowest for women.
Ms. Shrader tells us that she is one among millions who are
struggling to make ends meet in our country. She now resides in
Athens, WV where she is a master of school work student and
program assistant for the Upward Bound program at Concord
University.
Ms. Shrader, thanks so much for being with us.
STATEMENT OF SABRINA SHRADER, ATHENS, WV
Ms. Shrader. Thank you, Senator Sanders, Senator Baldwin,
and Senator Warren.
My name is Sabrina Shrader, and I am from a hollow in West
Virginia called Twin Branch where we made a good neighborhood
and community. Twin Branch is in McDowell County. It is one of
the poorest counties in one of the poorest States of the
country.
Because of inadequate healthcare, lack of transportation,
and lack of resources, I was born into a family that was
afflicted by domestic violence, child abuse, and mental
illnesses. These circumstances do not cause poverty; they are
caused by poverty. My parents were not perfect, but they taught
me to do my best, treat people how I wanted to be treated, and
to pray.
Influenced by poverty, their chances for success are often
swayed by drug abuse, poor healthcare, limited access to
healthy food choices, lifestyle habits such as smoking
cigarettes, and little interstate access.
Some say poverty is a death sentence. Frankly, I do not
know how many times I have been given the death sentence. Even
before I was born, doctors were questioning whether or not my
mom should have me because she was 16-years-old and her future
and mine looked bleak. The doctors did not even think I was
alive and they told her she would die if she chose to have me.
I was born 3 months early and I was born without fingernails,
eyelashes, and hair.
When I was in eleventh grade, my mom and I got into a
terrible car accident on our way to the bus stop. I had made
straight A's for most of my life. The car wreck left me, as
doctors said repeatedly, mentally challenged and paralyzed. I
learned to walk and talk again, and I bounced back with
resilience and I make good grades once again.
Then I got to college, and I got meningitis, and I was
given a death sentence once again. That time, I literally
waited to die in the hospital. Fortunately, I survived. I went
back to school, and I tried my hardest to learn, and here I am
in front of you all today still wrestling with residual
illnesses.
I have seen many die before their time. I have had family
members, friends, and classmates all die young. The deaths
started a couple of days after I was born, with my mom's
favorite aunt dying. Later, one of my best friends died from a
drug overdose. This past year, both of my stepsisters died. I
could go on and on about all the young people I have seen die
in West Virginia.
A strong correlation between poverty and life expectancy
exists. While many are born into poverty every day, poverty is
not a child's fault nor is it a family's. No one asks for a
life who is born into poverty, ask for a life that is
encompassed with suffering for everything you need to live for
every day, but nowadays, we seem more interested in taking
things away from these kids instead of giving them a fair shot.
Today, I am in the advanced standing master of social work
program at Concord University, and I am the program assistant
for the Upward Bound program there. This program gave me hope
when I was in the sixth grade of one day being able to go to
college. If it had not been for the program, I may not even
know what a college campus look like, let alone even know that
I could work at one.
I am the first person in my family to not only graduate
high school, but I am also the first to get a bachelor's
degree. If it had not been for TRIO programs like Upward Bound
and student support services, I do not know where I would be
today. TRIO programs help vulnerable kids who are labeled at-
risk survive and gives them hope to follow their dreams.
There are two Upward Bound programs at Concord University
and they serve 150 high school students from five high-need
counties in West Virginia. Sequestration cut our budget 5.23
percent and that means we will have to turn our backs on some
needy kids, and we face additional budget cuts.
Programs like Upward Bound and student support services
make it a little easier to try harder and keep a positive
attitude when times are tough and hope is rare. I watched my
classmates who did not have the TRIO program and they ended up
dropping out of school or using drugs. Some have committed
suicide. Life should not end this way.
TRIO programs make a huge difference for the kids living in
poverty-stricken areas. High school graduation rates are near
100 percent and postsecondary education rates are 70 percent
for poverty-stricken students enrolled in TRIO programs. TRIO
programs save lives.
People living in poverty do not have as good of odds of
living a long, happy, healthy life when compared to people who
can easily meet their basic needs such as food, clothing, and
shelter every day.
I am not a success story. I did not pull myself up by my
bootstraps. I am proof that we live in a country that even if
you work hard and even if you do everything that you are
supposed to do, you still may not have enough to make ends
meet.
I am still struggling to this day, but I am not struggling
alone. I am also a leader with the Our Children, Our Future
campaign. Our goal is to end child poverty in West Virginia,
and this last year, we already helped win six statewide policy
victories, from Medicaid extension to prison reform to
expanding school breakfast programs. For the first part of my
life, most people would not even listen to me, but this
campaign has listened and helped me organize in my community to
make a difference. Now I am showing everyone I know so that
everyone else knows they can make a difference too.
Thank you for your time and for listening. God bless you.
[The prepared statement of Ms. Shrader follows:]
Prepared Statement of Sabrina Shrader
My name is Sabrina Shrader and I am one among millions who are
struggling to make ends meet in America. Unfortunately, it had been
very difficult to succeed in the type of environment I have been given.
Because of inadequate healthcare, lack of transportation, and lack of
resources, I was born into a family that was afflicted by domestic
violence, child abuse, and mental illness. My parents weren't perfect
but they taught me to do my best, treat people how I want to be
treated, and to pray.
I am from a hollow in West Virginia called Twin Branch. I grew up
in McDowell County, one of the poorest counties, in one of the poorest
States of the country. Due to conditions influenced by poverty,
decreased chances for success are often swayed by drug abuse, poor
healthcare, limited access to healthy food choices, unhealthy lifestyle
habits such as smoking cigarettes and little interstate access.
Some say poverty is a death sentence. Frankly, I don't know how
many times I have been given that death sentence. Even before I was
born, doctors were questioning whether or not my mom should have me
because she was 16 years old and her future and mine looked bleak. The
doctors didn't even think I was alive and they told her she would die
if she chose to have me. I was born 3 months early and was born without
fingernails, eye lashes, and hair.
Another time I was given a not-so-positive prognosis was on a snowy
day. When I was in the 11th grade, my mom and I got into a terrible car
accident on our way to the bus stop. I had perfect attendance and had
made almost straight A's for most of my life. The car wreck left me as
doctors said repeatedly ``mentally challenged and paralyzed.'' I
learned to walk and talk again and I bounced back with resiliency and
started to make good grades again. I made it to college and there I got
meningitis and was given a death sentence once again. I literally
waited to die that time I was in the hospital. Fortunately, I went back
to school and tried my hardest to learn and here I am in front of you
all today.
Furthermore, I have seen many die before their time. I've had
family members, friends, and classmates all die young. The deaths
started a couple of days after I was born with my mom's favorite aunt
dying and another one of her favorite aunt's dying a couple months
after that. This past year, both of my stepsisters have died. One was
in a car accident and had water on her brain from drowning in the
river. She like me had learned to walk and talk again but after getting
pneumonia repeatedly she died in the hospital. The other didn't go to
the hospital when she needed to for not wanting to incur additional
medical bills and she died from a brain hemorrhage.
A strong correlation between poverty and life expectancy exists.
While many children are born into poverty every day, poverty is not a
family's fault and it is not a child's fault. No one who is born into
poverty asks for a life that is encompassed with suffering for
everything you need to live for every day. But nowadays we seem more
interested in taking things away from these kids, instead of giving
them a fair shot.
Today, I am in the Advanced Standing Master of Social Work program
at Concord University and I am the program assistant for the Upward
Bound program at Concord too. This program gave me hope when I was in
the 6th grade of one day being able to go to college. If it hadn't been
for the program, I may not even know what a college campus looks like.
I am the first person in my family to not only graduate high school but
to also get a bachelor's degree. If it hadn't been for TRIO programs
like Upward Bound and Student Support Services, I don't know where I
would be today.
TRIO programs help vulnerable kids survive and gives them hope to
follow their dreams. There are two Upward Bound programs at Concord
University and they serve 150 high school students from five high-need
counties in West Virginia. Sequestration cut our budget 5.23 percent
and TRIO programs face additional budget cuts thus causing fewer
children to be helped. Programs like Upward Bound and Student Support
Services make it a little easier to try harder and keep a positive
attitude when times are tough and hope is rare. I have seen other
people who are like me not be in TRIO programs and have suffered worse
consequences such as being compelled to use drugs and some have
committed suicide.
TRIO programs make a huge difference for the students living in
poverty stricken areas. High school graduation rates are near 100
percent and postsecondary education rates are 70 percent for poverty
students enrolled in TRIO programs. TRIO programs save lives. People
living in poverty do not have as good of odds of living a long happy
healthy life when compared to people who can easily meet their basic
needs such as food, clothing, and shelter every day.
Please don't misunderstand me when I say that I am not a success
story. I am still struggling but I am not struggling alone. I am also a
leader with the Our Children, Our Future Campaign. Our goal is to end
child poverty in West Virginia. For the first part of my life, most
people wouldn't even listen to me. But this campaign has listened and
helped me organize in my community to make a difference. Now I am
telling everyone I know. I am talking with my family, my church, my
workplace, and in my neighborhood so that everyone else knows they can
make a difference too. Thank you for your time and for listening. God
Bless You.
Senator Sanders. Well, thank you very much, Ms. Shrader,
for your very powerful testimony.
Our next witness is Dr. Michael Reisch, who is the Daniel
Thursz Distinguished Professor of Social Justice at the
University of Maryland School of Social Work in Baltimore. He
has held faculty administrative positions at four other major
universities and has played a leadership role in national and
State advocacy, professional and social change organizations
that focus on the needs of low-income children and families.
Dr. Reisch, thanks so much for being with us.
STATEMENT OF MICHAEL REISCH, Ph.D., MSW, DANIEL THURSZ
DISTINGUISHED PROFESSOR OF SOCIAL JUSTICE, UNIVERSITY OF
MARYLAND SCHOOL OF SOCIAL WORK, BALTIMORE, MD
Mr. Reisch. Good morning, Senator Sanders, Baldwin, Warren,
and Murphy.
Thank you for the opportunity to participate in this panel.
I know the effects of poverty, both personally and
professionally. I grew up in New York City in public housing.
My parents' families were on Home Relief during the Great
Depression. As a teenager, I was in a gang before being rescued
by social workers at the local Y. Sometimes, you get dealt the
right cards in life. Sadly, most people who live in poverty do
not.
Poverty is not merely a statistic, although we often treat
it in abstract terms. For tens of millions of Americans, it is
a persistent barrier to full participation in our society:
economically, politically, and socially. Of greater
significance, poverty is also a thief. It stills years of life
from its victims.
Americans in the top 5 percent of income distribution live
about 9 years longer than those in the bottom 10 percent.
Almost 50 million Americans, nearly 16 percent of the Nation,
now live below the official poverty line; the highest poverty
rate in a generation. The majority of people who are poor are
children and youth, the elderly and individuals with
disabilities. More than 20 million Americans experience deep
poverty; they live below 50 percent of the official poverty
line and 4 million Americans, half of them children, try to
survive on $2 a day. It is estimated that half of all adults in
the United States today are at economic risk in terms of their
levels of literacy, education, and healthcare.
But poverty is not merely a snapshot. Over 20 percent of
poor individuals remain poor for a year or more. They have a 1-
in-3 chance of escaping poverty in a given year and the odds
are much lower for African-Americans, Latinos, and female-
headed households. Roughly half of those who escape poverty
become poor again within 5 years.
This duration of poverty spells is compounded by the
widespread experience of poverty among Americans. Nearly 60
percent of the population and 91 percent of African-Americans
experience an episode of poverty during their lifetime of 1
year or more, and over three-quarters of the population
experiences at least a year of near-poverty. The impact of
cycling in and out of poverty has a profound effect on people's
health and longevity and on the stability of American
communities.
Children constitute the demographic cohort most likely to
be poor. Nationally, 22 percent of children under the age of 18
and over one-fourth of children under the age of 5 are in
poverty. Among African-American children, the figure is 36
percent. They are more likely to suffer from health ailments
such as lead poisoning, asthma, and anemia.
In addition, children growing up in low-income
neighborhoods are much more likely to encounter a variety of
environmental health and social hazards, such as elevated
exposure to lead and toxic pollutants, crime and violence,
dropping out of school, higher arrest rates, increased risk of
substance abuse, and greater exposure to sexually transmitted
diseases. These children are also less likely to finish high
school and go to college, and more likely to become involved
with the criminal justice system and develop chronic illnesses.
They are, in effect, permanently trapped in the vise of poverty
with all its deleterious effects on health and life expectancy.
Hunger is perhaps the most visible and painful symptom of
poverty. Today, over 50 million people, nearly 1 out of every 6
Americans experiences what is euphemistically called ``food
insufficiency.'' Nearly 17 million people endure a very low
food security and regularly run out of food several days each
month. Here in the Nation's Capital, nearly 31 percent of all
children live in households without consistent access to food;
the highest rate in the Nation.
Hunger, particularly in the first 3 years of life,
contribute significantly to a wide range of health problems,
lowers the psychological development, greater prevalence of
learning disabilities, and lower academic achievement. The
effects are similar among adults including women, and pregnant
women, and the elderly.
Let me illustrate by some data from two neighborhoods in
Baltimore that are just 2\1/2\ miles apart. The difference in
life expectancy between those neighborhoods is almost 20 years
regardless of race. In another neighborhood, Upton Druid
Heights which is primarily African-American, life expectancy is
30 years less than that of Roland Park, which is primarily
white.
If just 5 percent more people in Baltimore attended some
college and 5 percent more had incomes higher than twice the
Federal poverty line, we could save, each year, 247 lives,
prevent 27,000 cases of diabetes, and eliminate $202 million in
diabetes costs every year.
The impact of poverty on health and life expectancy of
millions of Americans illustrates the growing importance of our
fraying social safety net. Two years ago, these programs lifted
40 million people out of poverty including 9 million children.
They lowered our official poverty rate by almost 14 percent.
They are also fiscally prudent. Each 1 percent increase in
child poverty costs us approximately $28 billion a year and the
total costs associated with childhood poverty alone total
almost one-half a trillion dollars per year, or the equivalent
of nearly 4 percent of GDP.
Given the long term effects of poverty on people's life
expectancy, and the damage it does to the well-being of our
communities and our Nation, this is a time to expand, and not
reduce, these essential life-giving programs.
Thank you very much for your attention.
[The prepared statement of Mr. Reisch follows:]
Prepared Statement of Michael Reisch, Ph.D., MSW
Good morning, Senators Sanders and Burr. Thank you for the
opportunity to participate in this panel. I know the effects of poverty
both personally and professionally. I grew up in New York City in
public housing. My grandparents were immigrants, and my parents'
families were on relief during the Great Depression. As a teenager, I
was in a gang before being rescued by social workers at the local Y. I
was fortunate. Sometimes, you get dealt the right cards in life. Sadly,
most people who live in poverty do not.
From my research and professional practice experience, I have
learned that poverty is not merely a statistic, a snapshot of
individual and family well-being, although we often treat it in such
abstract terms. For tens of millions of Americans, it is a persistent
barrier to full participation in our society, economically, politically
and socially. Of greater significance, poverty is also a thief. Poverty
not only diminishes a person's life chances, it steals years from one's
life itself.
poverty in the united states
In 2012, using new methods of calculation, the U.S. Census Bureau
found that almost 50 million people in the United States were poor, 3
million more than in 2010. This is the largest number of people in
poverty since the United States began to measure poverty and the
highest poverty rate in a generation (U.S. Bureau of the Census,
2012a). Nearly 16 percent of the U.S. population now lives below the
official poverty line, which in 2013 is slightly above $23,000/year for
a family of four.
The majority of people who are poor are the most vulnerable members
of our society. Thirty-five percent are under the age of 18. Eight
percent are over the age of 65; 9 percent are between the ages of 18
and 64 and suffer from some type of disability (U.S. Census Bureau,
2012a). Over one-quarter of African-Americans and Latinos now live
below the poverty line; since 1980, they have been 2\1/2\-3 times more
likely to be poor than white, non-Hispanic Americans. Over \1/3\ of
African-American children and all young families are poor. Women,
particularly elderly women and single parents, are also more likely to
be poor at every educational level. Poverty among unmarried female-
headed households is nearly 40 percent--the highest rate of poverty for
female-headed households among 22 industrialized nations, about three
times higher than average (U.S. Bureau of the Census, 2012b).
Poverty in the United States is no longer confined to depressed
inner city neighborhoods or isolated rural areas. Since 2010, the
number and percentage of people in poverty increased in 17 States,
particularly in the South and West, and in suburban areas as well. It
is estimated that half of all adults in the United States today are at
economic risk in terms of their levels of literacy, education, and
health care.
Poverty is not only more extensive, it is also deeper and more
persistent. More than 20 million Americans, including nearly 12 percent
of African-Americans and over 10 percent of Latinos experience ``deep
poverty,'' defined as below 50 percent of the official Federal poverty
line (U.S. Bureau of the Census, 2012b; Acs & Nichols, 2010; Buss,
2010). Almost half of the families living in poverty actually live
below one-half of the official poverty line (U.S. Census Bureau,
2012a). Four million Americans, half of them children, live in extreme
poverty and try to survive on $2/day.
Over 20 percent of poor individuals are chronically poor (i.e.,
remain poor for a year or more). African-Americans, Latinos, and
female-headed households are over five times more likely than whites to
experience chronic poverty (U.S. Census Bureau, 2011). On average,
individuals in poverty have a one in three chance of escaping poverty
in a given year, although this probability is much lower among African-
Americans, Latinos, female-headed households, and larger families.
Roughly half of those who escape poverty become poor again within 5
years. Race, household status, and level of education are the key
factors determining whether an individual can permanently escape
poverty.
The duration of poverty spells is compounded by the widespread
experience of poverty among Americans. Nearly 60 percent of the
population experiences an episode of poverty during their lifetime of 1
year or more between the ages of 20-75, and over \3/4\ of the
population experiences at least a year of near poverty. Even more
striking is that 91 percent of African-Americans will experience
poverty at some point in their lives (Rank, 2004).
Many analysts believe that the poverty rate is underestimated by
half because it excludes homeless persons, people who are incarcerated,
and people ``doubled up'' and living with family members. It also fails
to consider the high cost of living in many metropolitan areas. Three-
fourths of Americans have incomes under $50,000/year, considerably
below what it takes to live a minimally decent life in major cities.
The official poverty line has not been adjusted to increases in real
income and changes in living standards since it was formulated nearly
50 years ago. If the poverty line was raised by 10 percent, about one-
third of the U.S. population (100 million persons) would be poor (Buss,
2010).
Given our knowledge about the long-term effects of poverty on
health, psychological development, and educational attainment, these
figures indicate the extent to which large numbers of the U.S.
population, particularly in communities of color or immigrant
communities, are at risk of a wide range of health, mental health, and
social problems (Monea & Sawhill, 2010; Edelman, Golden, & Holzer,
2010; Pavetti & Rosenbaum, 2010; Lim, Coulton, & Lalich, 2009; Fertig &
Reingold, 2008; Auerbach & Kellermann, 2011; Galea, Tracy, Hoggatt,
DiMaggio, & Karpati, 2011). The impact of cycling in and out of poverty
has a profound impact on people's health and longevity and on stability
of American communities (Acs & Nichols, 2010; Pavetti & Rosenbaum,
2010; Turner, Oliff, & Williams, 2010).
poverty among children
Children constitute the demographic cohort most likely to be poor,
a phenomenon unprecedented in industrialized nations. Nationally,
nearly 22 percent of children under the age of 18 and over \1/4\th of
children under the age of 5 were in poverty. Among African-American
children, the figure was 36 percent. Children who experience extended
periods of poverty are less likely to finish high school and go to
college. They are more likely to become involved with the criminal
justice system and to develop chronic illnesses. The life course risk
of poverty appears to have increased during the past several decades
especially for individuals in their 20s, 30s, and 40s (Sandoval, Rank,
and Hirschl, 2009; Alesina & Glaeser, 2004; Gornick & Jantti, 2012;
Smeeding, 2005)
Children in poverty are nearly three times as likely to have fair
or poor health and over twice as likely to have parents who report
symptoms of poor mental health (Loprest & Zedlewski, 2006; Case,
Fertig, & Paxson, 2005). Children in poverty are more likely to suffer
from various health ailments, such as lead poisoning, asthma, and
injury from accidents and violence (Aber, et al., 1997). Poverty and
poor nutrition produce a wide range of health and behavioral problems,
slower psychological development, greater frequency of learning
disabilities, and lower academic achievement. Nonwhite children in
particular are routinely exposed to high levels of neighborhood poverty
when growing up compared to their white counterparts (Drake & Rank,
2009). Exposure to such levels of poverty can have a profound impact
upon one's life chances and life expectancy.
For example, children growing up in neighborhoods marked by high
poverty are much more likely to encounter a variety of environmental
health and social hazards. These include elevated exposure to toxic
pollutants, greater likelihood of being victimized by crime and
violence, dropping out of school, higher arrest rates, increased risk
of substance abuse, and greater exposure to sexually transmitted
diseases (Evans, 2004). All of these can detrimentally affect a child's
health, which in turn, can have a profound impact upon that child's
health and economic well-being as an adult.
In addition, the infant mortality rate in the United States is
higher than in some developing nations and the U.S. life expectancy
ranks near the bottom among comparable industrialized countries. While
in neighboring Mexico 90 percent of all children under five are
immunized against childhood diseases, in some U.S. cities the rate is
below 50 percent (Children's Defense Fund, 2006). As a result of
persistent health disparities, Americans in the top 5 percent of the
income distribution can expect to live approximately 9 years longer
than those in the bottom 10 percent (Jencks, 2002). In two
neighborhoods in Baltimore, just 2.5 miles apart, the difference in
life expectancy is almost 20 years regardless of race (LaVeist, et al.,
2010).
Children born into low-income families also have far less
opportunity to be upwardly mobile than in the past. As educational
attainment and job skills become increasingly important determinants of
economic success in the global market, children from lower SES
backgrounds face mounting obstacles due to the inadequacy of the
schools most of them attend (Economic Policy Institute, 2012; Collins &
Mayer, 2010; Allard, 2009; Wacquant, 2009; Blank & Kovak, 2008). Yet,
in order to compete effectively for economic opportunities today, the
quality and the quantity of their education are critical. On both
counts, poverty and lower income status stunt the educational process.
Those growing up in poor households are likely to live in lower income
areas which have fewer financial resources to spend on their school
systems. This results in a significant reduction in the quality of
education that students who are poor receive.
Racial and class gaps in education, particularly in regard to
workforce preparation at the secondary school level, create especially
acute problems for African-American, Latino, and American Indian youth.
These problems are even more serious for the children of recent
immigrants, documented or undocumented, and for children in single
family female-headed households (Bureau of Labor Statistics, 2010;
Collins & Mayer, 2010; Wacquant, 2009; Soss, Fording, & Schram, 2011;
Braveman, et al,, 2011). They are, in effect, trapped in the vise of
poverty with all of its deleterious health effects.
Finally, child poverty is also a drain on the Nation's economy. Six
years ago, a study (Holzer, Schanzenbach, Duncan, & Ludwig, 2007)
concluded that ``the costs to the United States associated with
childhood poverty total about $500 billion per year, or the equivalent
of nearly 4 percent of GDP'' (p. 1). Each 1 percent increase in child
poverty costs the Nation approximately $28 billion/year.
poverty and hunger
Hunger is, perhaps, the most visible and painful symptom of
poverty. Today, over 50 million people in the United States--nearly one
out of every six Americans--experiences what is euphemistically called
``food insufficiency.'' This number has nearly doubled since 2000.
Nearly 17 million people endure ``very low food security.'' Their food
intake is below levels considered adequate by nutritional experts. They
regularly run out of food several days each month.
Poverty and hunger in the United States are not confined to any
geographic region or segment of the population. Although less visible,
they exist in startling and increasing numbers in suburbs and rural
areas. About \1/8\th of suburban households and over \1/7\th of rural
households experience food insecurity; almost 5 percent experience very
low food security. Nearly half of all Americans who receive food
assistance live in these communities. The problem is particularly
severe in southern and western States.
About one-third of the people who are hungry in America are
children and over 22 percent of all children nationally live in
households that experience hunger. In 36 of the 50 States, over 20
percent of children are hungry. Over 25 percent of African-American and
Latino households experience food insecurity. Here, in the Nation's
capital, nearly 31 percent of all children live in households without
consistent access to food--the highest rate in the Nation (Cohen,
Mabli, Potter, & Zhao, 2011).
It has been clearly established that hunger, particularly in the
first 3 years of life, has dramatic implications for children's future
physical and mental health, academic achievement, and economic
productivity. Children's hunger contributes significantly to a wide
range of health problems, to slower psychological development, greater
prevalence of learning disabilities, and lower academic achievement.
Children growing up in food insecure households are more likely to
require hospitalization, have more frequent instances of oral health
problems, and may be at higher risk for conditions such as anemia and
asthma. They may also be at higher risk for behavioral issues, such as
school truancy and tardiness, and more likely to experience a range of
behavioral problems including hyperactivity, aggression, anxiety, mood
swings, and bullying. Children who are chronically hungry often lag
behind in academic development, with clear implications for their
ultimate life chances.
The problem of hunger is slightly less severe, but still quite
serious, for working adults and the elderly population in the United
States. Among adults, food insecurity correlates strong with a variety
of negative physical health outcomes, such as diabetes, hypertension,
and various cardiovascular risk factors. There is also a demonstrated
relationship between hunger and higher levels of aggression and
anxiety. Pregnant women who experience food insecurity are at risk of
premature births, low-birth-weight babies, and other birth
complications. Women who experience hunger may be at greater risk of
major depression and other mental health problems. Food insecurity
among the children of mothers who are food insecure has also been
linked with delayed development, poorer parental attachment, and
learning difficulties during the first 2 years of life (Gundersen,
Waxman, Engelhard, Del Vecchio, Satoh, & Lopez-Betanzos, 2012).
Over 8 percent of households with one or more elderly Americans
experienced hunger in 2011, the last year for which complete data are
available. Seniors are more likely to be food insecure if they live in
a southern State, are younger, live with a grandchild, and are African-
American or Latino. Nearly one-third of these households have to choose
each month between purchasing food and paying for medical care and over
one-third of these households have to choose monthly between buying
food and paying for heat or other essential utilities. As a result,
over 14 percent of individuals in the United States who seek emergency
food assistance are over 65. Within slightly more than a decade, the
number of seniors experiencing food insecurity is projected to increase
by 50 percent when the youngest of the ``Baby Boom Generation'' reaches
age 60 (Coleman-Jensen, Nord, Andrews, & Carlson, 2012).
Growing hunger and poverty merely constitute the tip of the
iceberg. They reflect the widening gap in income, wealth, education,
employment, and health status between classes and races in the United
States. The relationship between family income and the lack of
opportunity to escape poverty and its lasting consequences is clear.
Yet, while there is a clear connection in the United States between
poverty and unemployment, the possession of a job itself does not
eliminate the risk of hunger. According to the Census Bureau, in 2010,
nearly 10 percent of all American families, almost 21 million people,
who are officially poor have at least one family member who is working
(De Navas-Walt, Proctor, & Lee, 2011). Their poverty is a direct
consequence of wage stagnation. From the late 1950s through the 1970s,
a full-time worker earning the minimum wage could maintain a family of
three at or above the poverty level. Today, this is no longer true
(Economic Policy Institute, 2012; Mishel & Shierholz, 2011).
poverty and health
Adults who are poor are more likely to have higher rates of heart
disease, cancer, diabetes, and virtually every other major illness and
cause of death (Kaler & Rennert, 2008). Among adults, poverty leads to
higher incidences of diabetes, hypertension, cardiovascular problems;
depression and other mental health problems among women, and, among
pregnant women, more premature births, low-birth-weight babies, and
birth complications. For them, poverty and hunger are not merely
statistics. They are, in the words of the Chilean poet, Pablo Neruda,
``the measure of man.''
Compounding these problems, people in poverty experience a wide
range of disparities in health and mental health care. These include:
(1) absence of care, especially preventative and primary care,
rehabilitation services, long-term care, oral health, and the
availability of affordable prescription medications; (2) poor access to
care: over 20 percent of African-Americans and over \1/3\ of Latinos
have no health insurance and there is a maldistribution of health care
providers in urban and rural areas; (3) inability to afford adequate
care as health care costs rise faster than inflation and States cut
back funding for Medicaid; (4) inappropriateness of care, particularly
a lack of sensitivity to the specific needs of impoverished persons
among health care providers; and (5) wide variations in the quality of
care. Today, the typical (or median) State provides medical assistance
to working parents who make less than 63 percent of the poverty line
($12,790 a year for a family of three) and non-working parents with
incomes below 37 percent of the poverty line ($7,063 a year). Only a
handful of States provide coverage to any low-income adults without
dependent children, regardless of how far below the poverty line they
fall.
Let me illustrate these problems with some statistics from the
Baltimore area where I live and work. In Baltimore, less than half of
the population has a college education, the lowest percentage in the
State of Maryland. Only 58 percent of city residents have incomes twice
that of the poverty line. If 5 percent more people attended some
college and 5 percent more had incomes higher than twice the Federal
poverty level, we could expect to save 247 lives, prevent 27,000 cases
of diabetes, and eliminate $202 million in diabetes costs every year.
In Baltimore County, if 5 percent more people attended some college and
3 percent more had an income higher than twice the Federal poverty
level we could expect to save 266 lives, prevent 305 cases of diabetes,
and eliminate $2 million in diabetes costs every year.
The lack of mobility out of low-income neighborhoods, particularly
for racial minorities, compounds the health effects of poverty. Nearly
half of African-Americans who live in high-poverty census tracts, for
example, still reside in a high-poverty census track 10 years later
Quillian (2003). In addition, 72 percent of African-American children
who grew up in impoverished neighborhoods live in similar neighborhoods
as adults. The absence of social mobility, generally associated with
the American Dream, demonstrates that neighborhood poverty has
prolonged and lasting consequences on the health, well-being, and life
expectancy of poor children, particularly children of color.
These consequences, however, are not limited to impoverished
children. Each night an estimated 1 million Americans have nowhere to
call home and over the course of any year 3 million Americans
experience homelessness for an extended period (National Coalition for
the Homeless, 2012). The U.S. Conference of Mayors' annual survey of
homelessness and hunger found that homelessness among families
increased by 16 percent from 2010 to 2011, with unemployment, lack of
affordable housing, and poverty being cited as the leading causes (U.S.
Conference of Mayors, 2011). For over 30 years, the impact of sub-
standard housing conditions and homelessness on people's health and
life expectancy has been well documented. In 2005, the National Health
Care for the Homeless Council reported that people experiencing
homelessness are three to four times more likely to die than their
housed counterparts, with the average age of death between 42 and 52
years of age (O'Connell, 2005).
Individuals who are homeless are the most desperate of the over 20
million households (17.7 percent of all U.S. households) who pay more
than half of their income for housing (Joint Center for Housing
Studies, 2012). The absence of a sufficient supply of affordable
housing contributes substantially to the high rates of poverty and near
poverty in the United States and to the millions of Americans who are
homeless, at risk of homelessness, or live in substandard, unhealthy,
and often dangerous housing. To illustrate: A family of four with an
income at the Federal Poverty Level ($23,050) has only 60.7 percent of
the income necessary to afford a two bedroom apartment at the Fair
Market Rent of $949/month; a single adult whose income is at the
Federal Poverty Level has only 39.6 percent of the income required to
afford an efficiency apartment at the Fair Market Rent of $705/month.
To state this situation another way, a renter earning the minimum wage
must work 101 hours to afford a two-bedroom unit at the Fair Market
Rent (Bravve, Bolton, Couch, & Crowley, 2012). Even an efficiency
apartment is out of reach for the minimum wage worker, who earns 53.4
percent of the amount necessary to make market rate housing affordable.
The impact of poverty on the health and life expectancy of millions
of Americans illustrates the growing importance of our fraying social
safety net. Without unemployment insurance, food stamps, Social
Security, and the Earned Income Tax Credit millions more nationally
would be vulnerable to the consequences of poverty outlined in my
testimony. In 2011, these programs lifted 40 million people out of
poverty, including nearly 9 million children. They lowered our official
poverty rate by almost 14 percent. Given the long-term effects of
poverty on people's life expectancy and the damage it does to the well-
being of our communities and our Nation, this is a time to expand and
not reduce these essential life-giving programs.
Thank you for your attention.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Senator Sanders. Thank you very much, Dr. Reisch.
Many questions come to mind, but let me start off with Ms.
Shrader. You grew up in a very poor county and in your
testimony, you talked about some of the travails, some of the
problems, some of the terrible things that happened to friends,
and acquaintances, and family members who you grew up with.
Can you say a few words about what life was like growing up
in McDowell County? What happened to some of your classmates
and family members as a result of the isolation and the reality
of life in McDowell?
Ms. Shrader. Thank you. Drug abuse is a problem that is
going on in that whole State of West Virginia, but I have seen
family members and friends and classmates, a lot of them, get
on drugs. All these people were born into poverty and fight to
survive every day. They fight every day to get food, to pay
their bills, and to have heat in their home.
Senator Sanders. OK. Thank you.
There has been a recurring theme, I think, from almost all
of the panelists that poverty for our country is, in fact, very
expensive. That while some of our colleagues can say,
``We can save the Federal Government. Why do we not
cut the TRIO program? We will save billions of dollars
doing that. Why do we not cut Medicaid? We could save
hundreds of billions of dollars.''
I think what some of you are telling us is that that may
not be the wisest course of action for some people. If they do
not have access to healthcare, if they do not have access to
education, if they do not have access to jobs and affordable
housing, we end up paying not only in terms of human suffering
and the shortening of life expectancy, but in actual dollars.
Dr. Woolf, do you want to elaborate on that point, please?
Dr. Woolf. Senator, it is a key point.
When we think about the burden on the Federal Government
spending brought on by Medicare and Medicaid, children's health
insurance, and so forth, most experts recognize that a lot of
that is being driven by the escalating epidemic of chronic
diseases--diabetes, heart disease, and so forth--which accounts
for the vast proportion of that spending, and those are
diseases that are directly correlated to socioeconomic
conditions.
Another example similar to my colleagues' presentations, we
know that diabetes mortality rates for middle-aged adults are 3
times higher if they have not graduated from high school
compared with if they have some college education.
Those huge differences in the prevalence of these expensive
chronic diseases cannot be ignored. Dealing with these
socioeconomic conditions that affect educational attainment and
socioeconomic status can markedly----
Senator Sanders. Can I interrupt you?
Dr. Woolf. Please.
Senator Sanders. I am chairman of the Veterans Committee,
and the V.A. actually does a fairly good job in addressing some
of these issues.
Is it fair to say that we know how to prevent, or at least
cutback, on the incidence of diabetes if we invested in
programs to do that?
Dr. Woolf. There is excellent research on important
behavioral strategies.
For example, the diabetes prevention trials have shown that
intensive exercise and physical activity can reduce the
incidence of new cases of diabetes by 15 percent. There are
other strategies that we need to think about outside of the
healthcare domain which is the focus of this hearing that can
also exert tremendous leverage on the prevalence.
Senator Sanders. In other words, investing in those
programs and cutting back on the incidence of diabetes may
actually not only ease human suffering, but save money as well.
OK. Let me ask. Several of you have made the important
point that, shamefully, the United States has, by far, the
highest rate of childhood poverty of any major country on
earth; it is 22 percent. Given all that we have heard this
morning, what do we look forward to? What is the future of this
country when so many of our kids are living in poverty? When
youth unemployment, an issue that is not discussed very much;
we talk about real unemployment. Do you know what youth
unemployment is? It is close to 20 percent in this country.
Kids who leave high school, do not have a job, what happens to
their lives?
What does that mean in terms of life expectancy, human
suffering, and the cost to the Federal Government? If a kid, a
low-income kid, drops out of school as a junior in high school,
what happens to that kid?
Yes, Dr. Kindig.
Dr. Kindig. As I mentioned in my testimony, we know the
effects of poverty and stress. There is a growing field in
biomedical science about how early these conditions affect even
within the womb, beginning with brain development. These things
get set into life so early that it is such a compelling reason
to start early because otherwise today the map for 20 years
from now is being set in stone.
I would just like to mention one other thing, Senator, that
has not come up. Dr. Woolf and others have also shown in their
work that in addition to our poor health outcomes in relation
to other countries, we spend about one-third more in medical
care than many of those that do better than us. We always
wonder, ``Where is the money to come from? '' But I am one of
those who believe, with Dr. Berwick, who used to run the Center
for Medicare and Medicaid services, that waste is theft. It is
theft from these other kinds of investments that we know would
be most health-promoting. There is a lot to be done there as
well.
Senator Sanders. Doctor, it is actually in many cases, more
than one-third; it is almost double what other countries are
spending.
Senator Warren.
Senator Warren. Thank you, Mr. Chairman.
I just want to pick up on the same theme. Let us start with
the trend lines; where we are heading right now. According to
the Commerce Department, inflation-adjusted incomes for middle-
class families have dropped 6 percent just in the last decade.
Meanwhile, the tax data show that nearly 20 percent of income
in the United States last year went to the top 1 percent of
earners. That is the largest share of income going to the top 1
percent since 1928; the Roaring Twenties.
Now, economists agree that this kind of inequality is bad
for growing an economy, but doctors, scientists, and health
researchers are now teaching us that this kind of inequality is
literally deadly for our families.
What I wanted to start with is a question about what
happens if these trends continue. If we continue to have an
increase in financial inequality, what would be the impact on
the health of families who are struggling to get into the
middle class, or families who are trying to stay in the middle
class?
Dr. Woolf, could you start us on that?
Dr. Woolf. I am glad you brought it up, Senator Warren. The
focus, obviously, in the last few comments has been on poverty,
which is obviously a great concern, but these economic trends
across the entire middle class of the United States also
carries significant health implications.
This trend of increasing income inequality and decreasing
median household income has been going on for some years now.
It is getting worse. And we know from a public health
standpoint that that carries important health consequences.
What it means to Senator Sanders' point is that our children
that are growing up under these conditions--we are raising a
generation that is going to be sicker.
When we think ahead to what the implications are, besides
the obviously important human toll that that will inflict on
that generation of higher chronic disease rates, that means a
sicker workforce, a less well-educated workforce, and for
American businesses greater difficulty competing against other
countries where they have less expensive healthcare costs and
healthier populations.
Senator Warren. Is there anyone who wants to add that?
Mr. Reisch.
Mr. Reisch. Yes, I think we are talking about a situation
right now which is creating a lack of mobility, both physical
mobility and social mobility for millions and millions of
people.
For example, it is harder and harder for low-income and
working-class families, and even middle-class families, to go
to college today. The cumulative amount of college debt now is
higher than the total credit card debt in the United States.
This is locking people into a lifestyle and physically into
communities which we know are less healthy and less able to
access all the benefits of our society.
Three-quarters of all African-American children who grow up
in low-income neighborhoods will remain in those neighborhoods
as adults. We are talking about creating a permanent social
stratification in our society which is socially unstable,
politically unstable, and economically damaging for our country
because we are depriving our Nation and individual people of
being able to contribute to the economic growth, prosperity,
and well-being of our whole society.
Senator Warren. Thank you.
Dr. Berkman, did I see that you wanted to add to that?
Ms. Berkman. I was just going to say that to increase this,
that the trend lines are bad and we see this evidence in health
and retirement survey, where we see cohorts have increased
morbidity, higher rates of diabetes, higher rates of heart
disease, higher rates of blood pressure. We see it in children
as well, who seem sicker, are more likely to be obese than
their counterparts a cohort or two ago.
I think the most important thing when we think about this
is that--and what you are onto--is that the social and economic
policies that Government has developed over years that may be
health-promoting are not counted as being health-promoting. We
do not think about that and the benefit side of the equation.
We only think about them in terms of the short-term
economic turnaround, or employment, or labor. When, in fact,
the spillover to health may be enormous and kind of trumps
many, many other health policies that we have.
Senator Warren. Let me pick up on this, then, because what
I am hearing from all of you is that we seem to be caught in a
vicious cycle here. That we have got struggling families who
are more likely to get sick and once someone is sick, that puts
even greater strain on the family. So that that puts more
strain on the family budget. It reduces the ability of parents
to work. It causes further financial struggles and we get a
real downward cycle here.
So the question is: how do you break out of that cycle?
What are the options available to us to move away from this?
Dr. Berkman, you have identified one. If we change that
calculation on how we understand costs and benefits, that we
could make different kinds of investments that would be
financially sensible investments, but we have to do the full
accounting.
What other ideas should we put on the table to address?
Dr. Woolf, did you want to add something more?
Dr. Woolf. We have an initiative at our Center that we call
Connecting the Dots, and it is basically this notion that Dr.
Berkman is mentioning of understanding how these policies--that
are not conventionally thought of as health policies--are vital
levers for affecting health outcomes.
One example I will talk about is education reform. Our
efforts to try to improve education beginning with preschool or
early childhood education, all the way from K-12, in helping
our young people achieve a college education and a graduate
school education are vital in a knowledge economy that are also
key levers in improving health outcomes.
A lot of the socioeconomic problems that we are talking
about here would be powerfully addressed by improving the
educational success of our young people. The U.S. rankings on
education are slipping behind other countries. We used to be
the most educated population post-World War II. Now our seniors
are the most educated seniors in the world, but our young
people are falling behind not only industrialized countries but
emerging economies because of our shortcomings in education.
Senator Warren. Mr. Chairman, can I have just another
minute to let others respond? Is that all right? I think Dr.
Eberstadt wanted to respond and I wanted to give him a chance.
Mr. Eberstadt. Thank you, Senator.
It is important to understand the role of social forces in
health outcomes in the United States and elsewhere. But it is
also important to understand the role of human agency: of
lifestyles, and behaviors, and practices, and outlook, and
attitudes, and objectives.
If social forces were really the determinative, the Latino
health story in America could not have occurred. We should want
to understand how disadvantaged groups in America--how people
with less privilege, less education, less income--sometimes
have excellent health outcomes. I think this is some of the low
hanging fruit in our situation today.
One of the reasons, perhaps, that we do not know as much
about this as we might has been that we have skimped on
investments in social and economic data systems for our country
as a whole. We were once not just the envy of the world with
our educational results; we were the envy of the world with our
statistical system. That is not true anymore.
We have held back on the investments in these data systems
that, I think, would help explain much more what is going on in
America.
Senator Warren. That is very valuable. Are we still OK or
do you want me to do another one?
Mr. Kindig.
Dr. Kindig. Just to build on that.
Senator Warren. But be really short here.
Dr. Kindig. Yes. Not only are the data systems, we just
need the dollars to invest in research and understanding what
are the most important factors.
We are pouring zillions of dollars into studying which
kinds of medical care factors are better than others; which
drugs, which procedures. That is important work to do. I do not
mean to bash that. But we spend almost no money on the
questions before you here.
What are the most cost-effective relative investments
across the determinants so that we can get a balanced
investment portfolio that will change the colors of these maps?
Senator Warren. Thank you very much, Mr. Chairman.
Senator Sanders. Very important point. Let me change gears
a little bit and Ms. Shrader, I am going to get back to you,
but I want to ask the doctors here a question. What is the
physiology of stress and poverty?
In other words, when most people think about poverty, they
say,
``Well, it is too bad. You have a broken down car; I
have a nice car. You live in a small apartment; I got a
really nice house. That is my advantage over you.''
But stress and poverty, wondering how am I going to feed my
family tomorrow, pay my bills, get the income I need to survive
takes a toll on human life, does it not?
What is the physiology between somebody who has a
meaningful job, is earning a decent income, is married, has
good social relationships and somebody who is in a very
different position? What happens physiologically, if you like?
What does that do to the body? Who wants to comment on that?
Dr. Kindig. I will be happy to start and I am not an expert
on this, but there are really two pathways through which these
income and educational disadvantages get under the skin. The
one is obviously if you do not have education or income, you
cannot get a good job. If you do not have income, you cannot
get health insurance, you cannot go to the fitness center.
Those sorts of things that you cannot do.
But more and more research these days, high quality
research is showing what you said, Senator Sanders, the stress
pathways independent of those other factors, that operate
really through neural endocrine mechanisms and neuro-
immunological mechanisms that really puts the body under stress
that produces some of these impacts on length of life and on
disease.
That is really a body of research of the last 10 or 15
years that is becoming unimpeachable and it happens early. That
is another matter. It begins to happen early.
Senator Sanders. Dr. Reisch.
Mr. Reisch. Yes, thank you.
I am not a medical doctor, but the studies that demonstrate
that the lack of choice and the increased stress that low-
income people experience increases their level of cortisol, and
we know that higher levels of cortisol are correlated with
cardiovascular disease and other chronic illnesses including
diabetes.
There was a study done in Louisville, KY, for example,
which did a very interesting analysis of the city based upon
the quintiles of income level. It demonstrated that morbidity
and mortality rates varied in exact correlation with social
stratification in that city. And I think the same thing applies
in places like Baltimore and Washington as well.
Senator Sanders. Yes, Dr. Berkman.
Ms. Berkman. I would just add that I think there are
multiple pathways that lead from socioeconomic conditions to
poor health outcomes. One of them is behavioral.
People tend to smoke more. They tend to consume more
alcohol. They tend to be more overweight. They make harder food
choices in part because of transportation needs and food. But
these stress pathways are also independent of that. It is very
clear that these behavioral pathways only explain a part of
that.
The stress pathways influence such things as inflammatory
markers, as other people have said, cortisol responses,
inflammatory markers and works with things like people sleep
less. People when they are stressed sleep less. We now know
that less sleep is related to metabolic function. It is related
to depression. These things also influence diabetes,
cardiovascular disease, hypertension, and a host of other
chronic diseases.
They also put you at risk for a whole set of mental
disorders that are very important and often underestimated in
these set up equations.
Senator Sanders. I think, as Senator Warren indicated, we
have a chicken and egg situation. When you are under stress,
it's hard to get a decent job. When you do not have a decent
job, hard to have an income to alleviate the stress again, so
housing and healthcare and everything else.
Let's jump a little bit. Dr. Woolf, you may have done the
research on this. How do we do as a Nation? Why is it that a
Nation which is as wealthy as we are does not do particularly
well compared to many other countries around the world in terms
of life expectancy? How does that relate to this whole
discussion?
Dr. Woolf. To repeat the point that has been made earlier,
we have higher poverty rates and higher income inequality
levels than they do in those other countries. That is certainly
part of it.
But in our analysis, comparing the United States with the
16 other high-income countries, it is also clear that,
obviously, they have poverty in other countries too, but there
appears to be more programming and policies in place in those
other countries to buffer the impact of material deprivation on
families. So that, in effect, children growing up in poor
families in these other countries are more protected from the
adverse health effects than American children are.
Our relative investment in those social programs, social
services, is quite striking. Elizabeth Bradley and her
colleagues at Yale University have compared the United States
with these other countries and find that we are an outlier in
the proportion of our dollars that we spend on healthcare
relative to those social programs. Whereas the countries that
spend much more on social programs than on healthcare are the
ones that are living longer.
Senator Sanders. And presumably saving money on healthcare
as well. Other thoughts on that?
Senator Warren.
Senator Warren. I just wanted to dig-in to this point a
little bit more. Thank you.
And that is, I was thinking about this, so healthy people
have stable, safe, clean housing. They live in safe
neighborhoods with sidewalks. They have lots of outdoor spaces.
Healthy people can afford nutritious food. Healthy people have
clean air to breathe. For many Americans, these necessities of
good health are luxuries they cannot afford.
If we have a system that is not investing in these cost-
efficient ways to keep people healthy, and a system that wastes
far too much money treating people after they become sick, it
is no wonder in this system that Americans are less healthy and
die younger than people living in other wealthy Nations.
But I wanted to dig-in to that just a little bit more, Dr.
Woolf, if I could. Can you tell us about the basic investments
that other countries in the Institute of Medicine's study make
outside direct healthcare investments that have helped them
achieve better outcomes?
Dr. Woolf. Well, due to the paucity of data that Dr. Kindig
mentioned, it is really hard to prove cause and effect.
Senator Warren. Fair enough.
Dr. Woolf. But we can see that these other countries that
have better health outcomes have different policies with
respect to some of the areas that Dr. Berkman mentioned, such
as parental leave, maternity leave, early childhood education.
We are outranked by other countries in the amount of resources
they invest in early childhood education. Job support and
workforce support for workers are more extensive in these other
countries.
Again, these are programs and services that help buffer the
potential adverse health impact on families that we think might
produce potential health benefits. But if I may step back out
of my medical roles, those are also policies that help people
achieve a stronger economic footing and increase their economic
prosperity so that they could be more productive workers, more
affluent consumers and so forth, and therefore boost the
economy. So it is a win-win improving their economic footing
and their health outcomes.
Senator Warren. The virtuous circle instead of the vicious
cycle.
Dr. Woolf. Exactly.
Senator Warren. Maybe I can ask this in a more detailed, in
another way. Dr. Kindig, I think in your written testimony, you
talked about Cambridge and Fall River, MA--you knew you would
catch my attention with that--how they made smart, community-
based investments.
I am going to ask you just to say a bit more about it, and
talk about how we could apply some of those same strategies to
the broader population, and what the major barriers are that
stand in our way right now.
Dr. Kindig. Right. Thank you for bringing up that point.
The time limitation, I could not say everything that I wrote,
but I was actually calling attention to a new program that we
work with at the University of Wisconsin along with the Robert
Wood Johnson Foundation. It is called the Roadmaps to Health
Prize. It sort of is a companion to the County Health Rankings
work that I mentioned before.
We are, the Foundation and with our staff, are every year
looking for those communities, not just the highest ranking
communities. That is what our rankings do. They are the highest
because they have all these things going for them.
We are actually looking for American communities that have
shown that they can be improving their health outcomes with a
balanced approach like we have just been talking about. Not
just in medical care, but actually in order to get a prize, you
have to show excellence in the behavioral area, in the
socioeconomic area, in the healthcare area, and particularly
looking for multi-sectoral approaches.
So the two places in your State, that was a little
embarrassing to give two to the one State, but sometimes----
Senator Warren. We are working on it.
Dr. Kindig. Yes, I know. But both of them, very different
communities as you know.
Senator Warren. Yes.
Dr. Kindig. But very remarkable partnerships coming
together with the healthcare community, the public health
community, the business community, community nonprofit
organizations, United Way, sort of come together and say, ``We
got a problem here to solve and how can we pull together to do
it? ''
Over time, this will be an ongoing, very high profile
program with the Robert Wood Johnson connection, over time with
six every year. When we get 20, 30, 50 of these type
communities, there will be little stories there that other
places can emulate and these are not the best-off places. Many
of these are challenged, as Fall River, for example, is a
challenged community for many historical reasons, but they are
finding a way to do it. There are stories that we can look to,
to make progress, and thank you for bringing attention to that.
Senator Warren. Well, thank you. Thank you, for your
bringing attention to it because I think it is a reminder. We
can do this in the United States. We have little pockets of
where we have begun to build on the research that you all and
the advice that you all have given. We just need to find ways
to support it and extend it across the country.
Thank you.
Senator Sanders. Let me ask, start with Dr. Kindig to
elaborate a little bit on a paper that he wrote earlier this
year which showed that female mortality rose in 43 percent of
U.S. counties between 1992 and 2006, and that is almost
incomprehensible. We talk about all of the advances we are
making in all kinds of areas, and yet in 43 percent of the
counties in America, women are living shorter lives.
What is that about? Why is that taking place?
And then I want to ask Ms. Shrader if she could, again,
coming from a county where life expectancy is low, to maybe
talk a little bit about women in those counties and how Dr.
Kindig's statistics are reflected in the real life that she may
have observed.
Dr. Kindig.
Dr. Kindig. Yes, thank you, Mr. Chairman. I have to tell
you honestly that when I saw that map, when my colleague Erica
Chang, one of our doctoral students, brought that map in, I
said, ``I do not believe this.'' We did two things that are
different.
One is we looked at change over time and that is not often
looked at. This is a change over time thing as opposed to how
it is in a certain time.
We also looked at the county level. When you look at
Nations and States, almost always mortality and life expectancy
go up because you average in the poor and the--but when you go
to the county level and look at change over time, these are the
kinds of results that you get, and we were shocked. We are not
the only ones that have found that.
Chris Murray and his colleagues at the University of
Washington have looked at also declining life expectancy,
showing also not quite as--it was a different data set in a
different time period.
Senator Sanders. But as I looked at that map, sorry to
interrupt you, if I look at that map, there is a lot of red in
the southeastern part of the country. Out in California and
southern California, it is all blue.
Dr. Kindig. Yes.
Senator Sanders. What is that about?
Dr. Kindig. In all of those counties, all the poor
performing counties have high rates of smoking, high poverty,
children in poverty, low high school graduation rates. They
have all those factors.
One of the striking things that we found and, actually
frankly, Senator, that I do not understand, when actually you
control for all of those factors, there still are regional
effects in the South and parts of the West that we do not
understand. We say in our paper there must be other cultural or
other factors that even go beyond the disadvantage that these
counties have from poor rates of the factors that we know
about, and it needs to be--I am quite interested in why that
is.
I have to tell you, most of the reports--and we have paid a
lot of attention to this--ask, ``And why is this more for
females than for men? '' We do not honestly know the answer to
that, but I know a lot of people are trying to dig-in to it and
that is why we need more research funding to answer these kinds
of questions.
Senator Sanders. Ms. Shrader, do you have any thoughts on
why that might be the case? Why is it conceivable that in
America--and in West Virginia among other places--women are
actually living shorter lives than used to be the case? Any
thoughts?
Ms. Shrader. Basically, they are working so hard and while
they are working so hard, they are suffering to make their
basic needs and to make their family's needs such as food,
clothing, and shelter. They do not have what they need to
succeed. They are stressed and overworked, but it is not their
fault. They need services and programs to help them improve.
Examples of how they are working so hard as they are trying to
be mothers, they are trying to work jobs, they are trying to
get an education. They know what the research says.
The research teaches children what you need to succeed, but
if you do not have it, you have to improvise and utilize all of
the resources and all of the people that is in your community
and your churches and in your family to try to do your best
with what you have, and hope that you are going to succeed.
Senator Sanders. Let me ask you maybe a dumb question here,
but is it your observation that a lot of folks are smoking and
not eating well in these communities? Is that something, too?
Ms. Shrader. There are a lot who are. However, farm to
school programs are coming into play in West Virginia. I have
seen them come into play in the northern-central parts of West
Virginia. They have yet to be big and booming in the southern
parts, but they are getting there. It takes time.
Senator Sanders. You made the point earlier, that just
programs like the TRIO program or Upward Bound giving kids the
opportunity of even knowing what a college is. You made an
interesting point that there are many kids that you have grown
up with who have never seen a college campus in their lives.
Exposing them to those opportunities has an impact on young
people's lives, would it not?
Ms. Shrader. It definitely does. When you are not exposed
to opportunities, period, in the world, you only know what
exists by what you see. There are all kinds of things on TV
that are not real, but they just may not know what they can do.
Also, sometimes you get told things that are not true. You
get told, ``You are stupid.'' Or, ``You are not going to amount
to anything.'' A lot of times kids are told this when they are
kids, and they end up believing these things, and it ends up
becoming a self-fulfilling prophecy. They do not believe in
themselves. It is real hard for them to try to do better.
Senator Sanders. You mentioned to me last night when we
chatted, Ms. Shrader and her husband and I chatted a little
bit, that there are a lot of kids who have never left their
county or left the State to see the rest. Well, it is true in
Vermont, as well, by the way. Elaborate a little bit on that.
Ms. Shrader. Well, there are a lot of people in McDowell
County statistically that do not have transportation. It is not
that their parents do not want to show them other parts of the
world, or other parts of the West Virginia, or other parts of
the country; they may not have access themselves to teach their
kids what is out there.
A way that they can learn about it is if other family
members have traveled, been in the military, for example. They
come back and they tell their stories. We all try to teach each
other about what is going on in the world.
Senator Sanders. Let me change gears a little bit.
Dr. Woolf made the important point, I think, that diabetes
is much more prevalent among lower income people at great cost
to the individuals and financial cost to the country. Go beyond
diabetes in terms of obesity, in terms of smoking, in terms of
child abuse.
How does class impact those factors, which play such an
important role in our lives?
Dr. Woolf. It is a pervasive issue. There are some diseases
where we do not see it quite as dramatically, but a very broad
spectrum of conditions that have these strong socioeconomic
determinants.
In addition to diabetes, I had mentioned cardiovascular
disease, pulmonary disease, arthritis, mental illness,
depression, for example, much higher rates. Studies that have
looked at disability rates and the productivity of workers also
find striking differences by educational attainment.
So that, again, is a factor that is affecting life
expectancy, it is affecting health burden.
Senator Sanders. Something as simple as, say, smoking--and
I do not know the answer to this--is it fair to say that
working-class people are more likely to smoke than upper income
people?
Dr. Woolf. There is a strong gradient in smoking rates
based on socioeconomic status since the release of the Surgeon
General's Report in the 1960s that revealed the role of
smoking. We see that in upper educated Americans, there was a
striking decrease in smoking rates. But in Americans with less
than a high school education, smoking rates are about triple of
those with more advanced education.
Senator Sanders. Which is going to lead to a whole host of
health problems, obviously.
Dr. Woolf. Exactly.
Senator Sanders. Senator Warren.
Senator Warren. Thank you, Mr. Chairman.
I would like to go back to a point that, I think, several
of you have emphasized, and that is one way to decrease the
health disparities between high-income and low-income people is
to look at the environments around them.
I am proud that in Boston, we have a model program, the
Asthma Prevention and Control program that is run by the Boston
Public Health Commission, and it has demonstrated success in
reducing asthma in our struggling neighborhoods by doing
exactly that. I just want to talk about the program for a
minute.
The Boston program addresses environmental triggers of
asthma by eliminating the pests that trigger asthma in our
homes, and by ensuring that the pesticides used to control the
pests are not themselves toxic.
The Boston program does home inspections to make sure the
property owners are keeping the residences up to code. The
Boston program performs home visits to teach families how to
reduce asthma and they teach in the language that the family
speaks. They give them the tools to prevent allergens in the
home.
The Boston program has been under the leadership of the
executive director, Dr. Barbara Ferrer, and the director of
Healthy Homes and Community Support, Margaret Reid and it has
just been an incredible success. I want to tell you about some
data that are not yet published from this.
A forthcoming report shows that the number of families who
have recently visited an urgent care for asthma dropped from 80
percent to 20 percent after participation in a home visit
program. In the public housing that was eradicated of pests,
the number of adult residents with asthma symptoms was cut in
half.
We are working to expand this initiative across
Massachusetts because we have seen it work. So what I want to
ask you to do is talk to us about how we implement programs
like this on a larger scale, not just for asthma, but for the
many diseases where we know that if we can improve
environmental factors, we can get better health outcomes at
lower costs for our citizens.
Who would like to do that? Dr. Berkman.
Ms. Berkman. First of all, I would like to congratulate you
on congratulating Barbara Ferrer, who has done an amazing job.
Senator Warren. Is she not fabulous?
Ms. Berkman. A completely amazing job in Boston city in
terms of understanding, really, the social determinants of
health approach. She is an enlightened person in terms of doing
this.
I think the point of it is that once you understand that
the determinants of health fit in neighborhoods, in schools, in
worksites, and you start turning your attention to what it
takes to improve those settings, there are millions of things
to do. There are sets of things in housing that get turned
around. There are sets of things in schools that we could be
doing.
And worksites, I think, are enormously hopeful because
people think that this is costly when, in fact, most companies
actually once they realize what is going on, think that it is
better for the bottom line. Our nursing homes, for instance,
think that turnover and sickness absence is devastating their
bottom line. And that these workplace policies will improve
their bottom line and be good for the health of workers and
their families.
I think if Barbara were multiplied times 100, that you
would like to get that kind of message out.
Senator Warren. So there is one strategy. We multiply
Barbara times 100.
Ms. Berkman. Yes.
Senator Warren. Again, I very much get the point. I think
it is a really powerful one.
Dr. Kindig, do you want to add?
Dr. Kindig. I would like to add to that. A lot of this work
is going on. That is the really wonderful example. But a lot of
this work is going on in communities in different places,
public health departments, but the resources that support it
are idiosyncratic, and fragmented, and come and go so that it
is not a sustainable model to scale.
I really think we have to find the same kind of resources
that deliver on this as we do in our healthcare programs. Every
Medicare patient that is treated, there is a little bit of
dollar that goes into graduate medical education, as you well
know. You do not have to put in a grant. It just happens every
day.
We need those kinds of resources. Hooking back to my other
comment about waste in healthcare, as we squeeze the waste out
and find the savings. So what is going to happen? Let us say we
are successful at that. We will see. So who gets the savings,
you know?
Right now in accountable care organizations, they are
talking about shared savings between the insurers and the
providers. There is nothing wrong with that, but a number of
thoughtful people have been talking about what about a
community part of the shared savings to go to these other
nonmedical care programs like you mentioned, housing lead
abatement or roach abatement that are, undoubtedly, health-
promoting. But where are the sustainable resources to sort of
deliver a dollar every day to the places that need it?
Senator Warren. Dr. Reisch.
Mr. Reisch. Thank you. I think it is also important, as you
suggested in your description of the program in Massachusetts,
to focus on community investment and community involvement, and
not just focus on individuals.
Individual and community behaviors are clearly linked, and
let me give you an example in terms of Baltimore, where there
has been an effort to reduce or eliminate the number of food
deserts in the city, which has been shown to be a major cause
of people's poor diets, which in turn, leads to obesity, which
in turn, leads to diabetes and cardiovascular disease.
There have been efforts, for example, to involve the
community in helping to site supermarkets, which bring healthy
food choices, to establish food co-ops, to establish farmers
markets in the community, to create community gardens, and so
forth. Well, those things not only have a positive effect upon
people's health individually and collectively, but also by
involving the community in it, it builds the community's
capacity to produce future changes and improves their
psychological well-being as well.
Senator Warren. Thank you very much.
Thank you, Mr. Chairman. I just want to say, since this is
my last round of questions, when we look at data like this and
we see that just cleaning up the environment means that we cut
visits to the emergency room for children with asthma from 80
percent to 20 percent, that is not only economically sound.
That is a lot of little kids who stayed in school those days,
or who were outside playing, or who were having fun instead of
spending their time in very expensive and very scary emergency
rooms struggling to breathe.
If those are not the investments we are willing to make,
what kind of a people are we? We have opportunities here. We
just have to seize them. Thank you.
Thank you, Mr. Chairman, for doing this.
Senator Sanders. Well, thank you very much, Senator Warren.
I did not want to leave Dr. Eberstadt out of the discussion
here because I think you made some good points. I think your
point was that we should take a hard look at why it is that
Asians in this country, Hispanics in this country have better
life expectancies than their socioeconomic conditions would
allow us to assume.
Do you have any guesses as to, in fact, why that is the
case?
Mr. Eberstadt. It is a really important question, Senator.
It is a really, really under-researched question. I hope that
you all can encourage some more research in this area. As Dr.
Kindig mentioned, this is a very underfunded area also.
I am just so struck by this Figure 8 in my prepared
testimony, which shows life expectancy in New York City by
ethnicity and by neighborhood status. You see on here that the
healthiest group in New York City, according to the New York
Department of Health study, are Asian-Americans who live in the
very poorest neighborhoods.
Senator Sanders. By ``healthy,'' do you mean life
expectancy?
Mr. Eberstadt. I am using that, yes, as a proxy.
Senator Sanders. Life expectancy.
Mr. Eberstadt. I am using that as a proxy.
Senator Sanders. Would you guess that maybe it has
something to do with family structure and so forth?
Mr. Eberstadt. That is the ghost in the room that has not
been mentioned yet, sir. There is, I think unfortunately, a
wealth of evidence that suggests there is a correspondence
between family structure and health outcomes, family structure
and poverty outcomes.
The fraying or disintegration of the U.S. family structure
for all ethnic groups over the past 50 years, has had really
frightening consequences. One of them is that a child in the
U.S.A. is more likely to live with just one parent today than
in any of the OECD countries, or at least the never-communist
OECD countries. We have a higher proportion of children living
with one parent than famous Scandinavia.
Senator Sanders. I think that is a good point.
If I can, because Senator Warren and I are the only people
here, we have all the time we want. I wanted to throw out
another point.
Dr. Kindig, the word ``community'' came up a whole lot, and
I think how we relate in the community, whether we feel
isolated or alone, or we are part of something larger than
that, I suspect plays a role in everything that we have been
talking about.
I have worked very hard, with some success, to expand
community health centers in the State of Vermont and throughout
this country.
Just as an example, just a couple of weeks ago HRSA, HHS,
announced they were going to spend $150 million--which around
here is not a lot of money--in starting up 236 new community
health centers in almost every State in this country providing
healthcare access to about 1.3 million people.
We talk about community. What impact does it have? The
basic point is made over and over again is that healthcare is a
lot more than health care. Right?
But on the other hand, if you have a community health
center where people can walk in the door and get the healthcare
they need when they need it, not delay going to the doctor, get
low-cost prescription drugs. Get mental health counseling when
they need it. Get dental care when they need it. To give you an
example.
Northern Vermont has a community health center, I visited
them during the summer. You know what they were running? They
were running a summer camp for virtually all the kids in the
town because they do not want kids hanging out on street
corners.
I was in the Bronx, NY at a community health center. They
are involved in food, making sure that kids are eating well.
They are involved in pregnancy prevention. They are dealing
with how to prevent AIDS, et cetera, etc.
I understand, again, that the main point of today is
healthcare is more than health care. But what would it mean to
this country if in every community in America, people could
walk into their doctor's office when they needed to and get the
broad counseling that they needed regardless of income?
What impact would that have on longevity?
Dr. Kindig.
Dr. Kindig. Yes, I really want to take this because I think
I told you in my testimony that I actually came of age and I am
probably the only one here who knows what OEO was, the Office
of Economic Opportunity.
Senator Sanders. Not the only one.
Dr. Kindig. I came of age in an OEO neighborhood health
center in the South Bronx and even before federally qualified
status. Your point is so well-taken, Senator. Not only at the
time, at that time, were those health centers innovative ways
of getting access to medical care which, of course, is a
determinant of health. We are not saying medical care is not a
determinant of health. It is just not the only one.
At that time those centers, particularly in that time, were
actually the hubs of other kinds of social services like school
programs, job training, and legal advocacy. It was just part of
the package.
I believe as over the years, particularly as OEO funding
went away, some of those other services fell off a bit, quite a
bit, even though the medical care role remains. I think many
health centers do, like you say, do-do that.
If you have another $150 million, I think you ought to not
only expand those health centers, particularly in the under-
served communities that need it, but make sure that they have
the resources to be a focal point, at least in those
communities, for this broader range of services like your
asthma program, or school health, or whatever that would be
responsive to the issues that we are talking about here.
Senator Sanders. Many of them do an extraordinary job, and
they are all different. The one in the Bronx was different than
the one in northern Vermont. But they look at the community as
a whole and they say, ``How do we keep people healthy? Yes, we
are going to treat them when they get sick. But how do we keep
them healthy? '' How can you ignore when the school down the
block is not doing a good job? Where there is not a grocery
store that people can buy decent food?
I think having professionals and having that kind of
community health center means a lot. But does anyone want to
elaborate on that? Yes, Ms. Shrader.
Ms. Shrader. Thank you. I just wanted to point out that I
am a fish-eating vegetarian. I lost 80 pounds in the past year.
This was after I watched the documentary on Netflix called
``Forks Over Knives.''
Research was done in Asia. These doctors saw where the
people in Asia were not dying from strokes, heart attacks, and
diabetes. And what they found is that they were so poor, they
could not afford meat. Once they made it into the middle class,
and they started eating meat, they started dying from high
blood pressure, all those issues. Thank you.
Senator Sanders. Dr. Reisch, did you want to?
Mr. Reisch. Yes, I think it is also important to add that
access means more than just physical proximity. It also means
the likelihood that the services that are provided are going to
be more culturally compatible to the needs of the community
because the community is involved in determining what those
services should be and what constitutes an appropriate service.
When I was growing up in public housing, we had a public
health nurse who was located on the grounds of the housing
project. That is where I got my childhood immunizations. The
startling statistic, which I think my public health colleagues
can validate, is that fewer children in the United States today
are immunized than that in Mexico, and that is something that
we should be totally ashamed of.
Senator Sanders. Yes, Dr. Kindig.
Dr. Kindig. Just building on the other point about the
health centers, and I cannot support it more than I did. But it
is a big country and I think we are going to find that
different solutions, even from where the organizing principle
is, maybe take place in different ways.
When the two communities that Senator Warren mentioned that
won the prize, one in Fall River was a very unusual, just sort
of a grassroots community organization that has grown over time
and they seem to have the leadership. The other one in
Cambridge is a combination of public health and innovative
healthcare system. One in Santa Cruz, CA, it was a United Way
that actually was the glue that pulled the partnership together
to make this happen.
I think centers, community health centers, can play a real
important role in many places. But there may be other ways in
other places given the history and the nature of the community
efforts.
Senator Sanders. Senator Warren. All right. First of all,
thank you so much, Senator Warren, for staying here throughout.
I think this has been a great discussion, I really do, and
I think you have shed light on issues that we just do not talk
about often enough. I think the point that you have made, if we
invest in our people, create a healthier, more loving society,
we end up not only creating a happier society with people that
are going to live longer lives. But you know what? We end up
saving money as well. We end up saving the taxpayers' money.
You guys have just been terrific and we appreciate, very
much, all of you for being here.
The record will remain open for 10 days to receive any
additional comments.
Thanks very much.
[Whereupon, at 11:40 a.m., the hearing was adjourned.]
[all]