The income gap is widening Alex Webb/Magnum

America’s health is in poor shape. The health gap between the rich and poor is now far bigger than the difference in income – that’s one of the messages from a series of papers published in The Lancet today.

But wealth is only part of the problem. Enduring personal and institutional racism means that African Americans and other ethnic minorities are faring worse than white people. For those groups, even a high income can’t buy better health, according to other new research.

Life expectancy in the US is lower than that of most other wealthy countries. While people who live in Canada can expect to reach 82.2 years of age, for residents of the US this figure is 79.3. This is partly down to a lack of health insurance. The introduction of the Affordable Care Act, known as Obamacare, reduced the number of uninsured people, but 27 million people still don’t have coverage.


Even those that have insurance can struggle to afford medical treatment and prescriptions, because insurance plans don’t always cover all healthcare costs. “Income inequality has increased dramatically, to levels not seen since before the Great Depression,” says Jacob Bor at Boston University in Massachusetts.

Bor’s team has analysed data on the life expectancies of the US’s richest and poorest from 26 studies covering the period between 1980 and 2015. They found that not only is the health gap growing, but health is becoming more strongly linked to a person’s financial status. “Your income matters more for your health than it did a decade ago,” says Bor. “Poverty is becoming a more important risk factor for early death.”

More than money

There are a few reasons why this might be the case, says Bor. Poorer people tend to get less education, are more likely to be out of work, and are at greater risk of substance abuse and self-harm as a result.

On the other hand, richer people in the US can buy the best health insurance, are more likely to live in neighbourhoods with abundant green spaces, and can more easily afford to eat well.

But a high income can’t buy health for everyone. African Americans have a shorter average lifespan, and are at higher risk of developing and dying from diseases like cancer and heart disease. To see whether this all comes down to lower incomes, Kanetha Wilson and her colleagues at Vanderbilt University in Nashville, Tennessee, compared the health of high-earning African Americans with that of non-Hispanic white people on similar salaries.

The team analysed data collected between 2000 and 2011 from more than 2500 people who earned $175,000 in 2000 – more than four times the average salary for that year. “We found that black people still had more health disadvantages compared to white people,” says Wilson. “They had greater odds of having hypertension, lower mental health and obesity.”

Wilson thinks that part of the problem may be the enduring racism that African Americans continue to experience in everyday life. “As a black woman, I know that just because you’re on a high income, doesn’t mean that people won’t treat you differently,” she says.

Chronic exposure to such “micro-aggressions” is known to cause stress and mental health problems. Such microagressions often take the form of subtle putdowns, and can make individuals feel undervalued, criminal or foreign. But structural racism is also problematic, writes Zinzi Bailey at the New York City Department of Health and Mental Hygiene and her colleagues in a separate study.

Bailey’s team has reviewed all the studies on racial discrimination and its effects on health in the US published between 2000 and 2016. They found that segregation still exists and is endangering lives. The average white American lives in an area that is 75 per cent white, while the average black American lives in areas that are 35 per cent white. These latter neighbourhoods tend to have lower-quality housing and greater exposure to toxins and crime – all of which are linked to poor health or early deaths.

Impacts of incarceration

The team also found that laws enacted as part of the “War on Drugs” and “tough-on-crime” policies have disproportionately targeted black people, despite the fact that illicit drug use was at similar levels among both black and white groups. One study found that by 2014, almost 3 per cent of all black men in the US were serving prison sentences of at least one year, the study found.

Nearly one in three black men in the US will be imprisoned at some point, say Christopher Wildeman of Cornell University, New York, and Emily Wang at the Bureau of Justice Assistance in Washington DC. The pair have just published a study that found the long-term health outcomes of people who have been in prison are dramatically lower, despite a temporary improvement when they are incarcerated.

This has far-reaching consequences. Nearly half of all black women in the US have a member of their family or extended family in prison, say Wildeman and Wang. Their review found that these women are more likely to develop mental health problems and cardiovascular disease, while their children are at a greater risk of early death. Daughters, in particular, seem to show more signs of inflammation and obesity.

Reforms in drug sentencing, and a possible decline in incarceration due to overcrowding and soaring costs, might improve this situation. Increasing health insurance coverage could also help. But people also need to be protected from poverty, says Bor. “It’s not just about access to medical insurance – it’s about ensuring everyone has access to safe housing and healthy food.”

Any attempts to solve the US’s health problems will need to focus on children, says Thomas McDade at Northwestern University in Evanston, Illinois. “There is a large and growing literature that shows improving environments in childhood has a legacy impact on health,” he says.

Given President Donald Trump’s policies to cut food vouchers for poor women and children, and repeal the Affordable Care Act, academics aren’t hopeful that things will improve. “We will likely see these gaps continue to widen,” says Bor.

Journal references: The Lancet, DOIs: 10.1016/S0140-6736(17)30571-8; 10.1016/S0140-6736(17)30569-X; 10.1016/S0140-6736(17)30259-3 and Preventive Medicine doi.org/10/b487

Read more: Trump wants to halt healthcare for 20 million poor US citizens