[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

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
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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

                              ----------                              


                      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.
---------------------------------------------------------------------------
    * 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
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confronting racial and ethnic disparities in health care. Washington 
(DC): National Academies Press; 2003.
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2010: with special feature on death and dying. Hyattsville (MD): NCHS; 
2011.
    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.
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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.
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health burden of selected social and behavioral risk factors in the 
United States: implications for policy. Am J Public Health. 
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    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.
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United States 1979-1985. Soc Sci Med. 1996;42(1):47-57.
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Mortality from leading causes by education and race in the United 
States, 2001. Am J Prev Med. 2008;34(1):1-8.
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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]. 
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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
    1. Woolf SH. Social policy as health policy. JAMA. 
2009;301(11):1166-69.
    2. Pleis JR, Lucas JW. Summary health statistics for U.S. adults: 
National Health Interview Survey 2007. Vital Health Stat 10. 
2007;(240):1-159.
    3. National Center for Health Statistics. Health, United States, 
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 
survival 1975-99. In: NCI Cancer Surveillance Monograph Series, Number 
4. Bethesda, MD: National Cancer Institute; 2003. NIH publication 03-
5417.
    7. Office of Management and Budget. Fiscal Year 2012 Budget of the 
U.S. Government. Washington, DC: Executive Office of the President of 
the United States; 2011.
    8. 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.
    9. Woolf SH, Jones RM, Johnson RE, Phillips RL Jr, Oliver MN, 
Vichare A. Avertable deaths in Virginia associated with areas of 
reduced household income. Am J Public Health. 2010;100:750-55.
    10. Virginia Commonwealth University Center on Human Needs. VCU 
Project on Societal Distress. http://www.societaldistress.org/. 
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.
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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]