{"id":179654,"date":"2016-02-22T17:30:16","date_gmt":"2016-02-22T22:30:16","guid":{"rendered":"http:\/\/webadmin.news-harvard.go-vip.net\/gazette\/gazette\/?p=179654"},"modified":"2019-03-04T14:32:49","modified_gmt":"2019-03-04T19:32:49","slug":"money-quality-health-care-longer-life","status":"publish","type":"post","link":"https:\/\/news.harvard.edu\/gazette\/story\/2016\/02\/money-quality-health-care-longer-life\/","title":{"rendered":"The costs of inequality: Money = quality health care = longer life"},"content":{"rendered":"\n\t
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\n\t\t\t\n\t\t\tHealth\t\t<\/a>\n\t\t\n\t\t

\n\t\tThe costs of inequality: Money = quality health care = longer life\t<\/h1>\n\n\t\t\t

\n\t\t\tFederal insurance has helped many, but system\u2019s holes limit gains, Harvard analysts say\t\t<\/p>\n\t\n\t\n\t

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\n\t\tAlvin Powell\t<\/p>\n\t\t\t

\n\t\t\tHarvard Staff Writer\t\t<\/p>\n\t\t\t\t\t<\/address>\n\t\t<\/div>\n\n\t\t

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Fourth in a series<\/a> on what Harvard scholars are doing to identify and understand inequality, in seeking solutions to one of America\u2019s most vexing problems. <\/em><\/p>\n

If you want to get an idea of the gap between the world\u2019s sickest and healthiest people, don\u2019t fly to a faraway land. Just look around the United States.<\/p>\n

Health inequality is part of American life, so deeply entangled with other social problems<\/a> \u2014 disparities in income<\/a>, education<\/a>, housing, race, gender, and even geography \u2014 that analysts have trouble saying which factors are cause and which are effect. The confusing result, they say, is a massive chicken-and-egg puzzle, its solution reaching beyond just health care. Because of that, everyday realities often determine whether people live in health or infirmity, to a ripe old age or early death.<\/p>\n

\u201cThere are huge inequalities in this country that often get overlooked \u2026 If you want to observe the problems of poverty and inequality, you don\u2019t need to travel all the way to Malawi. You can go to a rural house in America,\u201d said Ichiro Kawachi, John L. Loeb and Frances Lehman Loeb Professor of Social Epidemiology and chair of the Harvard T.H. Chan School of Public Health\u2019s Department of Social and Behavioral Sciences. \u201cIf you\u2019re born a black man in, let\u2019s say, New Orleans Parish, your average life expectancy is worse than the male average of countries that are much poorer than America.\u201d<\/p>\n\r\n\t\n\n\t

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Graphic by Judy Blomquist\/Harvard Staff\t\t\t<\/figcaption><\/figure>\n\t\n\t\r\n\n

Scholars say that inequality in health is actually three related problems. The first, and most critical, involves disparities in health itself: rates of asthma, diabetes, heart disease, cancer, drug abuse, violence, and other afflictions. The second problem involves disparities in care, including access to hospitals, clinics, doctors\u2019 offices, skilled professionals, medical technology, essential medicine, and proper procedures to deal with illness and disease. The third problem, one that has grabbed national headlines in recent years, is inequality in health insurance, the financial means to pay for the care people get to stay well.<\/p>\n

The three problems, scholars say, require interlaced solutions. President Obama\u2019s signature health care law, the Patient Protection and Affordable Care Act (ACA), has taken important strides in narrowing the gap in health insurance coverage, but those gains so far have translated to limited advances in ensuring access to quality medical care and even less progress in making diverse groups equally healthy.<\/p>\n

\u201cThat\u2019s an area<\/a> where there\u2019s less progress and more disappointment,\u201d said John McDonough, professor of the practice of public health at the Harvard Chan School. McDonough has worked on health care reform both in Massachusetts, which created the model for national care, and at the federal level.<\/p>\n

Disparities are built into the health care landscape, but there has been great progress in recent decades, according to S.V. Subramanian, professor of population health and geography at the Harvard Chan School and the Harvard Center for Population and Development Studies<\/a>. Life expectancy is increasing for African-Americans and the poor, albeit at a lower rate than for wealthy whites. Although stark disparities remain, the overall health picture in this country is one of improvement, analysts say.<\/p>\n

\u201cI sometimes feel that the public health narrative is all doom and gloom, but that\u2019s inaccurate,\u201d Subramanian said.<\/p>\n

Still, the remaining disparities are bell-clear in one of the bluntest measures of health: life expectancy, which varies, depending on a resident\u2019s race and ethnicity, as much as 30 years between the richest and poorest U.S. counties. That gap, Kawachi said, covers about two-thirds of the range seen between the world\u2019s healthiest and unhealthiest populations.<\/p>\n

In addition, a new study<\/a> by the Brookings Institution found that the gap has widened considerably. An upper-income man born in 1920, for example, could expect to live five years longer than someone at the lower end of the income spectrum. But for men born in 1940, that life-expectancy divide based on income has more than doubled, to 12 years.<\/p>\n

Health disparities are a major reason why U.S. life expectancy trails many peer nations, Kawachi said. According to a 2014 report by the Organization for Economic Cooperation and Development (OECD), U.S. life expectancy in 2012 was 78.7 years, 27th out of the group\u2019s 34 industrialized democracies.<\/p>\n

The fault line of income, and care<\/strong><\/h2>\n

Health disparities form along several societal fault lines, but analysts say the deepest and most persistent divide surrounds income. America\u2019s poor \u2014 of any race or ethnicity \u2014 are sicker than well-off Americans, Kawachi said. They get substandard care, live in poor housing and degraded environments, and have higher rates of suicide, violence, drug overdose, accidents, and smoking.<\/p>\n

\u201cIt\u2019s not only a question of racial disparities,\u201d Kawachi said. \u201cAt the root of it are unequal economic opportunities, unequal education, and despair.\u201d<\/p>\n

Disparities due to poverty hurt racial and ethnic minorities more than other groups because they make up a large proportion of the poor. Not only do they have more ailments, but they often get worse care.<\/p>\n

\u201cIf you\u2019re having a heart attack, there are very standardized protocols. If you\u2019re African-American, you\u2019re less likely to get those, even with the same health insurance, even with the same presentation,\u201d said Ashish Jha, the K.T. Li Professor of International Health, professor of medicine, and director of the Harvard Global Health Institute. \u201cIt\u2019s things like that that trouble us.\u201d<\/p>\n

Disparities in health, Jha said, begin at birth for many African-Americans and persist through life.<\/p>\n

\u201cOne thing we hoped is that the health care system would be part of the solution. What we find, over and over, is that not only does it not do that consistently, sometimes it makes things worse,\u201d Jha said. \u201cIt\u2019s obviously deeply disappointing.\u201d<\/p>\n

Though health professionals generally care deeply about their poor and minority patients, the problem nonetheless may be rooted in racism, according to David Williams, Florence Sprague Norman and Laura Smart Norman Professor of Public Health at the Harvard Chan School and professor of African and African-American studies in Harvard\u2019s Faculty of Arts and Sciences.<\/p>\n

In a recent article in the Journal of the American Medical Association, Williams, along with colleague Ronald Wyatt, cited a 2003 Institute of Medicine report that labeled widespread \u201cimplicit bias\u201d for differences in the care that African-Americans and other minorities receive. They said that substandard care leads to an estimated 260 premature African-American deaths each day.<\/p>\n\r\n

\u201cInsurance is not just supposed to get you access to care, it\u2019s supposed to keep you from getting evicted from your apartment because you paid your hospital bill instead of your rent.\u201d<\/p>\nKatherine Baicker<\/cite><\/blockquote>\r\n\n

\u201cAfrican-American individuals and those in other minority groups receive fewer procedures and poorer-quality medical care than white individuals,\u201d Williams and Wyatt wrote. \u201cThese differences existed even after statistical adjustment for variations in health insurance, stage and severity of disease, income or education, comorbid disease, and the type of health care facility.\u201d<\/p>\n

The result of that disparity and others fuels another one: shorter life spans for African-Americans, according to Thomas McGuire, professor of health economics in Harvard Medical School\u2019s (HMS) Department of Health Care Policy.<\/p>\n

\u201cIn terms of health, there\u2019s approximately a five-year penalty for being African-American compared to being a white male,\u201d McGuire said.<\/p>\n

While poverty, race, and ethnicity are key divides between wellness and ill health, another factor \u2014 often ignored \u2014 is geography, according to Katherine Baicker, C. Boyden Gray Professor of Health Economics at the Harvard Chan School and acting chair of the Department of Health Policy and Management.<\/p>\n

Health disparities exist regionally across America \u2014 Southern states, for example, have poorer care, according to a 2014 government report. There also are smaller pockets of poverty, such as depressed urban areas.<\/p>\n

\u201cI think an important factor that is sometimes overlooked is there are a lot of observed disparities in care \u2026 based on income, race, or ethnicity, that are attributable to the quality of care in some parts of the country lagging behind other parts of the country,\u201d Baicker said. \u201cSo it\u2019s as much about where you live as what your characteristics are.\u201d<\/p>\n\r\n\n

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