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The Increasing Divide: How Do We Improve Health In a Stratifying Society?

by Craig Klugman, Ph.D.

While editing a book chapter dealing with public health, I came across the author talking about inequalities in health. Then this followed my morning read of the paper that spoke about the declining middle class. Whereas making it into the middle class is a long-time American dream, the reality is different.

In 1971, the middle class comprised 61% of society. Today, only 49.9% of Americans qualify as being middle class. The rest are either in the upper or lower classes. More of the middle moved into the upper income class than the lower, while the earned income of those in the upper skyrocketed (from 29% of all US income in 1970 to 49% today—though those in the very top brackets make most of their money from sources other than income). But for those in the middle and lower income classes, aggregate income decreased. The Pew Research Forum, which conducted the study, cites this as evidence of the growing income divide in the U.S.: the rich get richer, the poor get poorer and the middle class disappears.

At the same time, the ability to move up from class to another has gotten more difficult. The U.S. is one of the most socially immobile countries in the industrialized world.

In public health circles, it is known that there is a strong correlation between health (longevity, chronic disease loads, disability, and acute illness) and income. People with higher incomes usually have better resources (insurance and cash) to access medical services. They can afford more nutritious food that is usually available close to home and they live in safe neighborhoods with plenty of facilities for exercise. They have access to good schools. When they are sick, they go to the doctor and get treatment.

However, in Chicago, where you live can change your life expectancy by 18 years. In areas where people with lower socioeconomic status can live, they tend to have higher disease loads whether. This could be a result having more physical (and potentially dangerous) jobs, more part-time jobs or without benefits, lower education, or other factors. There are fewer food stores and fewer of those that sell nutritious food that tends to be expensive. They are less likely to have insurance and cash to pay for medical care and even their subsidized plans from the ACA Marketplace are usually restrictive in terms of doctors and hospitals that take their insurance. Because access to health care (nevermind paying for it) is harder, they wait longer to get help and thus are sicker when they finally do see a doctor (often through an emergency room). Neighborhoods may be less safe and there are often fewer places to exercise.

The formula is simple: the higher your income, the longer you live.

There are two ways to respond to this growing inequality: (1) Redistribute income or (2) ensure real access to the conditions for healthy living (safe neighborhoods, affordable medical care, nutritious foods, quality education). Neither is easy and neither is cheap. Both require those with more money to assist those with less. As a nation, we used to do this. In 1955, the top income tax rate was 91% (25% for capital gains). For someone who made $400,000 or more per year in income ($3.5 million in 2015 dollars), he or she paid 91 cents of every dollar to taxes. In 2015, the highest rate is 39.6% with a capital gains tax (where most in the very upper reaches make their money) is 15%. But with credits and deductions, those in the top 1% pay a real rate of 22.83% and the top 0.001% pay 17.63%.

Most of the Republican candidates for president are calling for cutting taxes on income and capital gains even further. That will require drastic cuts in government services, programs that mostly benefit people in the lower economic brackets. Just this month the Senate voted to eliminate subsidies for the ACA Marketplace. The result for health will clearly be an increasing gap in longevity, chronic illness and disability. The problem with extreme income inequality is that it causes extreme health inequality.

Aristotle taught us that justice meant treating likes alike. The health of people is their health and all people deserve access to opportunities for good health. John Rawls said when new policies are made, that all groups can benefit as long as those with the least benefit the most (maximin principle). What is clear is that the current direction of income redistribution in this country is hurting our collective health. If we consider all lives to be valuable (a precept that Kant and I hope most of us hold), then we need to do more.


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