The high cost of inequality

For years now I've engaged in conversations with urban health workers regarding the effect of poverty itself, poverty as a self-understanding or psychic reality on overall health outcomes.  The impact of the "wealth gap" on people who live in inner city poverty has been obvious to me for a long time.  Economic status in a market-driven, ad-filled, consumer society that measures even human value in material terms must have a negative impact on the soul's of low-income folks.  It's part of what's back of teens going beserk over a pair of Nike's. 

Or take access to health care.  One of the reasons that universal, national health care is so important for public health improvement may relate to just this value proposition.  If my nation, my larger community believes that I am valuable enough to receive a health care plan/card regardless of my net worth or annual income, the provision of that benefit alone will likely improve my overall health.  I've felt that way for a long time. 

Nicholas Kristof provides insight into a body of serious research that confirms my hunch.  I'd love to hear your reaction after you've read what he says. 

Equality, a True Soul Food

By NICHOLAS D. KRISTOF
Published: January 1, 2011
The New York Times

John Steinbeck observed that “a sad soul can kill you quicker, far quicker, than a germ.”
That insight, now confirmed by epidemiological studies, is worth bearing in mind at a time of such polarizing inequality that the wealthiest 1 percent of Americans possess a greater collective net worth than the bottom 90 percent.

There’s growing evidence that the toll of our stunning inequality is not just economic but also is a melancholy of the soul. The upshot appears to be high rates of violent crime, high narcotics use, high teenage birthrates and even high rates of heart disease.

That’s the argument of an important book by two distinguished British epidemiologists, Richard Wilkinson and Kate Pickett. They argue that gross inequality tears at the human psyche, creating anxiety, distrust and an array of mental and physical ailments — and they cite mountains of data to support their argument.

“If you fail to avoid high inequality, you will need more prisons and more police,” they assert. “You will have to deal with higher rates of mental illness, drug abuse and every other kind of problem.” They explore these issues in their book, “The Spirit Level: Why Greater Equality Makes Societies Stronger.”

The heart of their argument is that humans are social animals and that in highly unequal societies those at the bottom suffer from a range of pathologies. For example, a long-term study of British civil servants found that messengers, doormen and others with low status were much more likely to die of heart disease, suicide and some cancers and had substantially worse overall health.

There’s similar evidence from other primates. For example, macaque monkeys are also highly social animals, and scientists put them in cages and taught them how to push a lever so that they could get cocaine. Those at the bottom of the monkey hierarchy took much more cocaine than high-status monkeys.

Other experiments found that low-status monkeys suffered physical problems, including atherosclerosis in their arteries and an increase in abdominal fat. And as with monkeys, so with humans. Researchers have found that when people become unemployed or suffer economic setbacks, they gain weight. One 12-year study of American men found that when their income slipped, they gained an average of 5.5 pounds.

The correlation is strong around the world between countries with greater inequality and greater drug use. Paradoxically, countries with more relaxed narcotics laws, like the Netherlands, have relatively low domestic drug use — perhaps because they are more egalitarian.

Professors Wilkinson and Pickett crunch the numbers and show that the same relationship holds true for a range of social problems. Among rich countries, those that are more unequal appear to have more mental illness, infant mortality, obesity, high school dropouts, teenage births, homicides, and so on.

They find the same thing is true among the 50 American states. More unequal states, like Mississippi and Louisiana, do poorly by these social measures. More equal states, like New Hampshire and Minnesota, do far better.

So why is inequality so harmful? “The Spirit Level” suggests that inequality undermines social trust and community life, corroding societies as a whole. It also suggests that humans, as social beings, become stressed when they find themselves at the bottom of a hierarchy.

That stress leads to biological changes, such as the release of the hormone cortisol, and to the accumulation of abdominal fat (perhaps an evolutionary adaptation in preparation for starvation ahead?). The result is physical ailments like heart disease, and social ailments like violent crime, mutual distrust, self-destructive behaviors and persistent poverty. Another result is the establishment of alternative systems in which one can win respect and acquire self-esteem, such as gangs.

Granted, humans are not all equal in ability: There will always be some who are more wealthy — and others who constitute the bottom. But inequality does not have to be as harsh, oppressive and polarized as it is in America today. Germany and Japan have attained modern, efficient economies with far less inequality than we have — and far fewer social problems. Likewise, the gap between rich and poor fell during the Clinton administration, according to data cited in “The Spirit Level,” even though that was a period of economic vigor.

“Inequality is divisive, and even small differences seem to make an important difference,” Professors Wilkinson and Pickett note. They suggest that it is not just the poor who benefit from the social cohesion that comes with equality, but the entire society.

So as we debate national policy in 2011 — from the estate tax to unemployment insurance to early childhood education — let’s push to reduce the stunning levels of inequality in America today. These inequities seem profoundly unhealthy, for us and for our nation’s soul.

More on health care debate from T. R. Reid (Final)

Here are the final collection of quotes from The Healing of America:  A Global Quest for Better, Cheaper, and Fairer Health Care:

There are useful approaches, ideas, and techniques we could learn from health care systems that are fairer, cheaper, and more effective than ours (pp. 44-45).

Most nations try to drop the Out-of-Pocket Model as they grow richer (p. 151).

In the process (of trying different reforms), the basic moral question that should drive reform --- do we want to give everybody access to health care? – gets swept aide… “The Clinton defeat,” argued political analyst Ezra Klein, “taught many that health care is simply too big, too complicated, and too dangerous to touch” (p. 163).

Both countries (Taiwan and Switzerland) decided that society has an ethical obligation – as a matter of justice, of fairness, or solidarity – to assure everybody access to medical care when it’s needed. The advocates of reform in both countries clarified and emphasized that moral issue much more than the nuts and bolts of the proposed reform plans. As a result, the national debate was waged largely around ideals like “equal treatment for everybody,” “we’re all in this together,” and “fundamental rights” rather than on the commercial implications for the health care industry… President Clinton emphasized economics. The moral issue that drove major change in Taiwan and Switzerland never got really moving in the USA (p. 182).

Whereas all other nations work from the time the line turns blue to introduce a healthy new person into their health care system, the United States first attends to its poorest mothers and newborns in the hospital on delivery day… Until we adopt a health care system that encourages it, preventive health care will remain largely inaccessible to far too many Americans (p. 202).

Which inequalities will society tolerate? Is it acceptable that some people are left to die because they can’t see a doctor when they get sick? That question encompasses a more basic question: Is health care a human right?... Is medicine a commodity to be bought and sold, a product like a car, a computer, a camera?... The creation of a national health care system involves political, economic, and medical decisions, but the primary decision to be made is a moral one (p. 212).

Twenty two thousand Americans (USA) die each year from treatable diseases (because they do not have health care) (p. 217).

Does a wealthy country have an ethical obligation to provide access to health care for everybody? Do we want to live in a society that lets tens of thousands of our neighbors die each year, and hundreds of thousands face financial ruin, because they can’t afford medical care when they’re sick?... Every developed country except the United States has reached the same conclusion: Everybody should have access to medical care. Having made that decision, the other nations have organized health care systems to meet that fundamental moral goal. . . .

At the start of the twenty-first century, the world’s richest and most powerful nation does not have the world’s best health care system. But we could… We can heal America’s ailing health care system – and the world’s other industrialized democracies can show us how to do it (p. 239).

(Though there is legitimate debate re. the health care rankings of countries, this is clear and not in dispute): there is a coterie of developed countries that are providing quality health care, distributing it fairly and equitably – and doing all that for much less money than the United States is spending (from the conclusion, at end of appendix – p. 256).

More on health care debate from T. R. Reid (Part 3)

The following from T. R. Reid's important book, The Healing of America:  A Global Quest for Better, Cheaper, and Fairer Health Care:

Even if we found good ideas in other countries, could the United States find the political will at home to use them? One basic political truth about American health care is that our system is strongly resistant to change. The vested interests that are doing well in the health business now – insurance companies, hospital chains, pharmaceutical companies – have blocked significant restructuring of our system (p. 22).

All the developed countries I looked at provide health coverage for every resident, old or young, rich or poor. This is the underlying moral principle of the health care system in every rich country – every one, that is, except the United States (p. 23).

Every country on earth faces difficult problems in providing medical care to its people. Nobody’s system is perfect. There are health care horror stories in every wealthy country – and they’re true… But for all of their problems, the other industrialized countries tend to do better than the United States on basic measures of health system performance: coverage, quality, cost control, choice. What are we doing wrong? (pp. 26-27).

When it comes to the essential task of providing health care for people, the mighty USA is a fourth-rate power (p. 28).

How many people go bankrupt because of medical bills? In Britain, zero. In France, zero. In Japan, Germany, the Netherlands, Canada, Switzerland: zero. In the United States, according to a joint study by Harvard Law School and Harvard Medical School, the annual figure is around 700,000.

For all the money America spends on health care, our health outcomes are worse on many basic measures than those in countries that spend much less (p. 31).

The United States is the only developed country that relies on profit-making health insurance companies to pay for essential and elective care. . .

All the other developed countries have decided that basic health insurance must be a nonprofit operation. In those countries, the insurance plans – sometimes run by government, sometimes private entities – exist only to pay people’s medical bills, not to provide dividends for investors… The U.S. private insurance industry has the highest administrative costs of any health care payer in the world (pp. 36-37).

If insurance companies have to cover everybody who applies, they need to have everybody in the insurance pool to cover the costs. All other developed countries require both “guaranteed issue” and the “individual mandate.” The United States has neither (p. 38).

More on health care debate from T. R. Reid (Part 2)

As promised, here's more from the important book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, by T. R. Reid:

Our nation's healthcare system has become excessively expensive, ineffective, and unjust. Among the world's developed nations, the United States stands at or near the bottom in most important rankings of access to and quality of medical care. (pp. 8-9).

The thesis of this book is that we can bring about fundamental change by borrowing ideas from foreign models of health care. For me, that conclusion stems from personal experience. I’ve worked overseas for years as a foreign correspondent; our family has lived on three continents, and we’ve used the health care systems in other wealthy countries with satisfaction. But many Americans intensely dislike the idea that we might learn useful policy ideas from other countries, particularly in medicine. (p. 11).

Anyone who dares to say that other countries do something better than we do is likely to be labeled unpatriotic or anti-American… The real patriot, the person who genuinely loves his country, or college, or company, is the person who recognizes its problems and tries to fix them. (p. 13).

Eisenhower’s strategic plan envisioned months of painful slogging across a shattered German countryside. But then his forward commanders reported an amazing discovery: a broad ribbon of highway, the best road system anybody had ever seen, stretching straight through the heart of Germany. This was the autobahn network… “I decided, as President, to put an emphasis on this kind of road-building.” (President Eisenhower – which led to the “Dwight D. Eisenhower System of Interstate and Defense Highways” – the Interstate Highway System). Eisenhower, the pragmatic commander, was willing to borrow a good policy idea, even if it had foreign lineage. (pp. 14 & 15).

Each nation’s health care system is a reflection of its history, politics, economy, and national values. (p. 16).

More to come. . .

A book to read. . .

Over the next few days and posts I intend to share quotes from a rather remarkable book, The Healing of America:  A Global Quest for Better, Cheaper, and Fairer Health Care [New York: The Penguin Press (2009)] by T. R. Reid. 

The subject of the book has grown in importance to me as this past week I learned of a young man who is my friend who is facing brain surgery and has no health coverage, public or private.  Unless something changes, after any treatment he receives his "pre-existing condition" will end any chance of coverage going forward. 

T. R. Reid is not afraid to bring a moral argument to this discussion.  I appreciate that about him. 

Here's the first installment:

Government and academic studies report that more than 20,000 Americans die in the prime of life each year from medical problems that could be treated, because they can't afford to see a doctor. That doesn't happen in any other developed country. Hundreds of thousands of Americans go bankrupt every year because of medical bills. That doesn't happen in any other developed country either. Efforts to change the system tend to be derailed by arguments about “big government" or “free enterprise" or “socialism" -- and the essential moral question gets lost in the shouting (p. 2).

All the other developed countries on earth have made a different moral decision. Countries that are just as committed as we are to equal opportunity, individual liberty, and the free-market have concluded that everybody has a right to health care -- and they provide it. One result is that most rich countries have better national health statistics -- longer life expectancy, lower infant mortality, better recovery rates for major diseases -- than the United States does. Yet all the other rich countries spend far less on healthcare than the United States does.

The primary issue for any healthcare system is a moral one (p.3).

[Note:  this book was the subject of our discussion at CDM's monthly Urban Engagement Book Club.]