Disparities, Inequalities, and the Pursuit of Health Equity

Introduction

Individuals in the US suffer bad health, die much earlier and younger, and endure severe societal dysfunction than those in other wealthy countries. The common explanation for this is that they engage in numerous adverse health behaviours and lack access to appropriate healthcare and medicines. Health disparities and health inequalities are widely comprehended compared to health equity because it connotes difference in the health results as a result of unjust or unfair or unbalanced societies and systems (Braveman, 2006). The term health inequality is linked to socioeconomic inequalities seen in many societies. While the American citizens have significantly worse health than the inhabitants of other rich countries, within the United States' boundaries is a peculiar health inequality, with marginalized groups and more impoverished individuals being less healthy than the affluent ones. One factor why the US has high inequality is because it is a developed country that still depends on private healthcare insurance (Vladeck, 2003). Consequently, individuals who have corporate-sponsored plans access better healthcare services. Before creating and implementing the Affordable Care Act, at least 20% of US citizens had no or little health insurance (The Commonwealth Fund, 2019). Almost 45,000 of this percentage died annually due to their inability to afford expensive healthcare (PNHP, 2020).

This paper aims to investigate this difference in health inequality, particularly between wealthy individuals and the poorer individuals in ethnic minority groups found in the United States. This paper will also examine the causes or reasons behind the health inequalities, as well as how the problem can be reduced or eliminated, for instance, through policy changes.

Health Inequality in the United States

Poor health has been reported among families that earn low income in the United States. For instance, from 2011 to 2013, 38% of those earning less income than 22,500 USD per year had poor health. In comparison, only 12% of households earning over 47,700 USD annually have poor health (Hero, Zaslavsky, and Blendon, 2017).

The wealthiest 1% have been found to live about 15 years more than the most impoverished 1% counterparts (Chetty et al., 2016). For women, this disparity is at ten years. Most low-income and poor adults experience chronic health conditions that make them too ill to bathe, dress, or eat without help. The probability of their children developing obesity and having high blood lead levels is also higher than those in high-income earning families (Chokshi, 2018). Evidently, in the United States, structural inequality is worsening. The United States has experienced more than 275% of tax income increase, especially from 1979 to 2007. This made about 65% of the 1% wealthiest individuals richer. During this period, the 5% wealthiest individuals had a 10% share increase in their total income, with the wealthiest 1% gaining even more. On the other hand, low income and impoverished families saw their income shrink by about 2%. Economic mobility became worse during this period (Harris and Sammartino, 2011). The financial crisis that occurred in 2008 worsened income disparity further by making the wealthiest wealthier (Fligstein and Rucks-Ahidiana, 2016). Emmanuel Saez and Thomas Piketty (2013) note that the top 10% highest earners took more than 50% of the whole income in 2012. This was the highest amount and percentage in a century.

Today, the concern is that 50% of healthier individuals are found in upper social classes. Besides the US's low overall life expectancy, it also has worse health disparities/inequality between less or more privileged than the other rich countries (Singh et al., 2017). The overall health disparity in the United States has been rising steadily since the 1990s. Men living in Washington, DC, lived 17 years longer than those in close Maryland’s suburban. Health inequalities in the United States are more pronounced among grownups than in children (Marmot and Bell, 2009).

Comparisons of Canada and the United States show that income-inequality causes more severe effects on US citizens' health than Canadians. More impoverished individuals in the US are worse off compared to their Canadian counterparts. Medical care access is not the reason for the health disparity differences between the two countries. The negative health-related behaviours are particularly common among individuals in lower socioeconomic classes in both countries. However, those adverse behaviours’ health effects are far less in Canada than in the United States (McGrail et al., 2009). Racial health outcome inequality is substantially higher in the United States than in Canada (Siddiqi and Nguyen, 2010).

The context, including the physical, social, and societal environment where personal health-linked behaviours occur, play a significant role in creating specific behavior-related health outcomes. For instance, life expectancy for about 20% of women in the United States has been falling because of an increasingly toxic environment with odourless, invisible, and lethal gas particles inhaled into the lungs (Ezzati et al., 2008).

Some groups in the United States are more affected by health disparities compared to others. Those belonging to ethnic minority groups, black people and other people of colour, and the immigrants, particularly those found in low-income or low-income families, experience difficulty accessing high living standards and better healthcare services. Unlike the 1980s when immigrants like the Hispanics had better health results compared to their non-Hispanic whites, a situation known as the Epidemiologic or the Hispanic Paradox (Valles, S.A., 2016) because of their culture which helped regulate their lifestyle in terms of economic and social life, today they experience health inequalities which came about as they continued to live in the United States, when they began to adopt unhealthy living and due to increased number of stressors (Kaestner et al., 2009). These people also experienced challenges like finding better-paying jobs due to discrimination or racism and found themselves doing the less paying jobs that are more stressful and do not allow for acceptable living standards. Therefore, they adapted to poor lifestyles in terms of cheap, unhealthy foods, less developed living places, smoking, lack of exercise, among other adverse behaviours that exposed them to health conditions such as diabetes and cardiac-related diseases like blood pressure and stroke (Islam, 2019).

Evidence point to the relevance of early life in determining a person’s health as an adult. Different health-linked factors present today are linked to what occurred in people’s lives during childhood. This is the phenomenon termed intergenerational transfer health status transfer where stress, environmental, and nutritional factors during childhood influence a future generation (Payne, Pesando and Kohler, 2019). Getting exposed to different forms of stressors during childhood is a critical biological mechanism that can produce health inequalities. For instance, a mother’s lifetime nutrition prior to becoming pregnant is vital to her child’s health. Similarly, either rapid catch-up growth or low birth-weight can result in chronic illnesses later in life, factors determined by fetal growth in a mother and a person’s early childhood development and growth. Early life can last a lifetime and can create health disparities in society (Li et al., 2005).

Factors that Cause Healthcare Inequality

Healthcare inequality is linked to six major factors in the United States. The first one is poverty. Evidence suggests that the most impoverished in society are more at risk of becoming sick. (Shaw, 2016) found in 2012 that low-income households had a 15% more chance of getting health complications compared to affluent families. 38.6% of the low-income families were more likely to be affected by hypertension (high blood pressure) than 29.9% of the wealthiest families who were likely to suffer from this condition.

Additionally, health disparity in this group of people is caused by their presence in low-income or less developed neighbourhoods where access to quality health care services or medical technology is challenging. This problem is exacerbated in rural places. According to Artiga and Damico (2016), Southern states in the United States have also shown poorer care compared to northern states, as indicated by the difference in their health outcomes. The rising cost regarding the poor people belonging to these groups or people has made it difficult for them to access quality care. A study by (Christopher et al., 2018) indicates that medical expenses placed over seven million Americans under the federal poverty index/line. Collection agencies have turned medical bills into their most significant source of income. Meanwhile, more than half a million people in the US have become medically bankrupt (Christopher et al., 2018).

The lack of medical insurance in this group of people in the United States has also affected medical care quality. Many poor and working individuals in the United States lack access to Medicaid. Even though they can receive Obamacare subsidies, the policy is only useful in specific doctors' practices and hospitals (Healthcare.gov, 2020). The situation is even worse in rural places because the covered services may not be sufficient. Insurance firms have been raising the cost of medical care for patients through expensive deductibles that have more than doubled since 2007 (Rae et al., 2019). Meanwhile, employers lowered their share. From 2016 through 2018, the overall deductible in staff-sponsored health plans rose to 255% (The Kaiser Family Foundation, 2015)

Moreover, evidence shows that poor health in less developed places and disadvantaged minority groups has created a poverty cycle (The Kaiser Family Foundation, 2017). These authors opine that people in poor health are likely to end up in the vicious and endless poverty cycle. For this group of people finding and sustaining high-paying employment positions are difficult, particularly if they are chronically ill. Health conditions such as drug addiction and alcoholism can make having continuous employment impossible. Lastly, The Kaiser Family Foundation (2017) claims that elderly people belonging to ethnic minority groups and low-income earning families have a high chance of being unwell. In 2016, more than half of the individuals under medical care had fewer annual incomes of less than 26,000 USD. Additionally, about 10% of them lived under the US poverty level (The Kaiser Family Foundation, 2017).

Health Inequality Theories

Health inequality theories are essential for differentiating the causes of health disparities and finding appropriate actions to reduce or eradicate what is referred to as mortal injustices. The theories examine policy rhetoric and the different socioeconomic situations people live in that lead to health disparities. Most of the theories show that the contrasting socioeconomic situations people find themselves in are mostly shaped by political choices and processes (McCartney, Collins, and Mackenzie, 2013).

The Artefact Theory

This theory suggests the relationship between health outcomes and social status markers. According to this theory, social status measures like occupational group, social class, education, area deprivation, and income determine the quality of care an individual receives. Low-class status individuals do not receive quality care as those in higher class statuses (McCartney, Collins, and Mackenzie, 2013). For example, in the United States, black families and others in minority ethnic groups have experienced racial discrimination for years. They have been looked at as second-class citizens and have only had limited employment opportunities with little pay. The low income and lack of employment opportunities have put them in low social status with limited access to high quality healthcare.

Selection Theory

This theory comprises of Health selection, intelligence, and meritocracy. Health selection theory suggests that health selection impacts might be liked to inequalities because those with poor health might experience social selections. In this theory, there is an association between a low social class/status and ill health. Health and intelligence are also associated closely with this theory. The theory proposes that intelligence is linked to factors like chance and reverse causation. Based on reverse causation, intelligence differences can also lead to health disparities. For instance, the concept suggests that intelligence gained later in a person’s life may be impacted by an illness like a stroke—lastly, meritocracy, or social mobility theorem. Based on the meritocracy theory, Scandinavian countries have experienced more meritocracy or social democracy than other countries. The “more able” individuals born in low socioeconomic groups, having higher intelligence, can still rise to more respected higher socioeconomic classes in adulthood. In contrast, the less able people, born in higher socioeconomic groups, may go through a socioeconomic slide. The meritocracy theory suggests that those in lower socioeconomic groups are at increased risk of developing health complications compared to those in higher socioeconomic groups (Crozier, 2018). Individuals in low-income households and those in minority groups in the US who experience discrimination also lack access to quality education and other important services. Therefore, they lack the knowledge necessary to look for better medical services.

Cultural and Behavioural Theory

This theory proposes that differences in high prevalence behaviours like illicit drug use, alcohol consumption, smoking, physical activity, and diet between groups and differences in dominant cultures are the critical reasons for health disparities. Accordingly, common behaviours found in low socioeconomic groups like smoking and alcoholism, poor diet, and lack of physical exercise can explain why this group is highly affected by health conditions like obesity, diabetes, and stroke compared to higher socioeconomic groups (Shaw, 2005). Evidence shows that many black people and low-income individuals living in the United States often engage in high prevalence behaviours like illicit drug use, alcohol consumption, smoking, physical activity, and poor diet. They lack sufficient money to acquire good living standards and healthy living (Shaw, 2005).

Cultural Theories

There are several expressions in this theory, like Durkheim’s anomie theory (Savolainen, 2000), Oscar Lewis’ poverty culture thesis (de Antuñano, 2019), and the dependency or underclass culture theory by Charles Murray. This theory contends that some poor populations develop certain aberrant cultural styles that have negative or destructive implications for health and social outcomes. Oscar Lewis claims that poverty culture is self-perpetuating. On the other hand, Murray says that government structures' dependency culture needs responsibilization to make the poor withdraw from the state provisions and become independent (Oversveen et al., 2017). These theorists also contend that besides the poor living behaviours portrayed by low income earning individuals in the United States, they also lack basic services or the ability to provide for themselves independently. It is important for the government to put up structures which promote a culture of independence among such groups (Oversveen et al., 2017).

Reducing Health Inequality in the United States

One vital challenge in the United States’ public in understanding this form of inequality in a broader way. There is a need for a perspective that shifts focus on holistically thinking about health to provide everyone, regardless of their economic class, race, or any form of difference, with equal access to quality healthcare services. The country’s political choices, which deem how wealth and income are apportioned, seem to be a vital factor that impacts people's kind of health in the United States. There is an increasing awareness that more economic growth in the country or developed countries may be less beneficial for this category of people's well-being, especially in reducing health disparity (Wilkinson and Picket, 2009). This is evident in rich countries where health appears to be better while experiencing economic downturns compared to during booms. Therefore, it is necessary to find other solutions linked to economic equality, fairness, or justice rather than focusing solely on economic growth (Lee et al., 2020).

In the United States, public health departments work to lower this health disparity. However, given that the employees work for the government with limited tools due to political constraints, the departments find themselves caught up in an endless debate reforms in healthcare, distracting them from the more important and basic problem of health inequality. It also evident that early life in the production of good health later in life, policies should be developed, which can help establish good health through future generations. The United States currently is alone among the wealthiest nations that do not entirely offer paid prenatal or parental leaves. Additionally, universal welfare benefits lack in the country (Heymann et al., 2009). The US can thus enact and enforce legislation that can make these welfare benefits possible for all people regardless of their economic class, racial backgrounds, or differences. These legislations can result in cost-effectiveness and reduce health disparities to a level consistent with other European countries (Lundberg et al., 2008).

The Federal Government in the United States has started recognizing health inequality as a problem that needs structures and resources to be eliminated, particularly racial disparity. Progress towards this goal has been slow and limited. Satcher et al. (2005) claim that about 83,000 deaths in the United States can be averted by eliminating the gap seen between white and black mortality. From the 1990s to around 2005, disparities between the results for Non-Hispanic Whites and Non-Hispanic Blacks have shown improvements for indicators like low-birth weights, as well as mortality measures like heart diseases, cancer, and motor vehicle crashes, but not for homicide and infant mortality. The average mortality difference between Blacks and Non-Hispanic Whites have widened during this period. While the United States has experienced little progress, the situation has worsened, as illustrated by Orsi et al. (2010), who claim that states like Chicago show increasing health inequality between Whites and other ethnic minority groups.

Bilal et al. (2019) recommend the formation and implementation of Universal Healthcare, which provides medical cover to all people regardless of their class, ethnicity, or financial ability. This universal healthcare will lower healthcare costs because the system will allow the government to control the cost of medical services and medication through regulation and negotiation. The system will also force hospitals to offer the same standard of care, unlike today’s environment where hospitals compete for and target wealthy individuals, charging more for higher profits. This system will empower community-based healthcare centres to reduce care inequality, particularly in low-income areas (Bilal et al., 2019).

Conclusion

People in different socioeconomic groups, especially those in low-income and poor households and ethnic minority groups in the United States, find difficulty accessing high-quality healthcare facilities and services. This paper has highlighted different theories, including the artefact theory, which highlight the relationship between health outcomes and the social status markers like occupational group, social class, education, area deprivation, and income determine the quality of care an individual receives. Selection Theory points out that those in lower socioeconomic groups are at high risk of developing health complications than those in higher socioeconomic groups. Cultural and Behavioural theory suggests that common behaviours found in low socioeconomic groups like smoking and alcoholism, poor diet, and lack of physical exercise can explain why these groups are highly affected by health conditions like obesity, diabetes, and stroke compared to higher socioeconomic groups. Cultural theories contend that some poor populations develop certain aberrant cultural styles with negative or destructive implications for health and social outcomes. Structural theory suggests that difference in socioeconomic situations of different social groups such as access, environment, power, wealth, and income lead to the difference in health outcomes. It is necessary to put in place policy measures that can help increase access to quality healthcare for everyone regardless of ethnicity, race or income, or social class.

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References

Artiga, S. and Damico, A., 2016. Health and health coverage in the South: A data update. Henry J. Kaiser Family Foundation.

Bilal, U., Cainzos-Achirica, M., Cleries, M., Santaeugènia, S., Corbella, X., Comin-Colet, J. and Vela, E., 2019. Socioeconomic status, life expectancy and mortality in a universal healthcare setting: An individual-level analysis of> 6 million Catalan residents. Preventive medicine, 123, pp.91-94.

Braveman, P., 2006. Health disparities and health equity: concepts and measurement. Annu. Rev. Public Health, 27, pp.167-194.

Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., Bergeron, A. and Cutler, D., 2016. The association between income and life expectancy in the United States, 2001-2014. Jama, 315(16), pp.1750-1766.

Chokshi, D.A., 2018. Income, poverty, and health inequality. Jama, 319(13), pp.1312-1313.

Christopher, A.S., Himmelstein, D.U., Woolhandler, S. and McCormick, D., 2018. The effects of household medical expenditures on income inequality in the United States. American journal of public health, 108(3), pp.351-354.

Crozier, G., 2018. Race and education: Meritocracy as white middle class privilege. British Journal of Sociology of Education, 39(8), pp.1239-1246.

de Antuñano, E., 2019. Mexico City as an Urban Laboratory: Oscar Lewis, the “Culture of Poverty” and the Transnational History of the Slum. Journal of Urban History, 45(4), pp.813-830.

Emmanuel Saez, and Thomas Piketty, 2013. Striking it Richer: The Evolution of Top Incomes in the United States (updated with 2012 preliminary estimates). Berkeley: University of California, Department of Economics. http://elsa. berkeley. edu/~ saez/saez-UStopincomes-2012. pdf et The World Top Incomes Database. http://topincomes. gmond. parisschoolofeconomics. eu.

Ezzati, M., Friedman, A.B., Kulkarni, S.C. and Murray, C.J., 2008. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med, 5(4), p.e66.

Fligstein, N. and Rucks-Ahidiana, Z., 2016. The Rich Got Richer: The Effects of the Financial Crisis on Household Well-Being, 2007–2009. In A Gedenkschrift to Randy Hodson: Working with Dignity. Emerald Group Publishing Limited.

Harris, E. and Sammartino, F., 2011. Trends in the Distribution of Household Income between 1979 and 2007. Congress of the United States, Congressional Budget Office.

Hero, J.O., Zaslavsky, A.M. and Blendon, R.J., 2017. The United States leads other nations in differences by income in perceptions of health and health care. Health Affairs, 36(6), pp.1032-1040.

Heymann, J., Flores-Macias, F., Hayes, J.A., Kennedy, M., Lahaie, C. and Earle, A., 2009. The impact of migration on the well-being of transnational families: New data from sending communities in Mexico. Community, Work & Family, 12(1), pp.91-103.

https://www.healthsystemtracker.org/brief/deductible-relief-day-how-rising-deductibles-are-affecting-people-with-employer-coverage/ [Accessed 27 December 2020].

Islam, M.M., 2019. Social determinants of health and related inequalities: confusion and implications. Frontiers in public health, 7, p.11.

Lee, H., Kim, D., Lee, S. and Fawcett, J., 2020. The concepts of health inequality, disparities and equity in the era of population health. Applied Nursing Research.

Li, R., Darling, N., Maurice, E., Barker, L. and Grummer-Strawn, L.M., 2005. Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National Immunization Survey. Paediatrics, 115(1), pp.e31-e37.

Lundberg, O., Fors, S., and Lennartsson, C., 2008. Health inequalities among older adults in Sweden 1991–2002. European journal of public health, 18(2), pp.138-143.

Marmot, M.G. and Bell, R., 2009. How will the financial crisis affect health? BMJ, 338.

McCartney, G., Collins, C. and Mackenzie, M., 2013. What (or who) causes health inequalities: theories, evidence and implications? Health Policy, 113(3), pp.221-227.

McGrail, K.M., Van Doorslaer, E., Ross, N.A. and Sanmartin, C., 2009. Income-related health inequalities in Canada and the United States: a decomposition analysis. American journal of public health, 99(10), pp.1856-1863.

Orsi, J.M., Margellos-Anast, H. and Whitman, S., 2010. Black–white health disparities in the United States and Chicago: a 15-year progress analysis. American journal of public health, 100(2), pp.349-356.

Oversveen, E., Rydland, H.T., Bambra, C. and Eikemo, T.A., 2017. Rethinking the relationship between socio-economic status and health: Making the case for sociological theory in health inequality research. Scandinavian journal of public health, 45(2), pp.103-112.

Payne, C.F., Pesando, L.M. and Kohler, H.P., 2019. Private intergenerational transfers, family structure, and health in a sub-Saharan African context. Population and development review, 45(1), p.41.

PNHP, 2020. "New Study Finds 45,000 Deaths Annually Linked to Lack of Health Hoverage," Page 2229. https://pnhp.org/ [Accessed 27 December 2020].

Satcher, D., Fryer Jr, G.E., McCann, J., Troutman, A., Woolf, S.H. and Rust, G., 2005. What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. Health Affairs, 24(2), pp.459-464.

Savolainen, J., 2000. Inequality, welfare state, and homicide: Further support for the institutional anomie theory. Criminology, 38(4), pp.1021-1042.

Shaw, K.M., 2016. Chronic disease disparities by county economic status and metropolitan classification, Behavioural Risk Factor Surveillance System, 2013. Preventing chronic disease, 13.

Shaw, M., 2005. Health Inequality: An Introduction to Theories, Concepts and Methods. Mel Bartley. Cambridge: Polity Press, 2004, pp. 224, £ 16.99 (PB), ISBN: 0745627803. International Journal of Epidemiology, 34(2), pp.500-502.

Siddiqi, A. and Nguyen, Q.C., 2010. A cross-national comparative perspective on racial inequities in health: the USA versus Canada. Journal of Epidemiology & Community Health, 64(01), pp.29-35.

Singh, G.K., Daus, G.P., Allender, M., Ramey, C.T., Martin, E.K., Perry, C., De Los Reyes, A.A. and Vedamuthu, I.P., 2017. Social determinants of health in the United States: addressing major health inequality trends for the nation, 1935-2016. International Journal of MCH and AIDS, 6(2), p.139.

The Commonwealth Fund, 2019. Underinsured Rate Rose From 2014-2018, With Greatest Growth among People in Employer Health Plans | Commonwealth Fund. [online] Available at: [Accessed 27 December 2020].

The Kaiser Family Foundation, 2015. "2015 Employer Health Benefits Survey," https://www.kff.org/report-section/ehbs-2015-summary-of-findings/ [Accessed 27 December 2020].

The Kaiser Family Foundation, 2017. "How Many Seniors Live in Poverty?" https://www.kff.org/medicare/issue-brief/income-and-assets-of-medicare-beneficiaries-2016-2035/ [Accessed Nov. 2, 2020].

Valles, S.A., 2016. The challenges of choosing and explaining a phenomenon in epidemiological research on the “Hispanic Paradox”. Theoretical Medicine and Bioethics, 37(2), pp.129-148.

Wilkinson, R., and Picket, K., 2009. The Spirit Level. City More Equal Societics Almost Always.