Income inequality in the United States has increased steadily in recent years, and is now at its highest level since the 1920s. Mexico, Chile, and Turkey are the only members of the Organization for Economic Cooperation and Development (OECD) with higher levels of income inequality than the United States, according to the Gini coefficient. The amount of income distributed to the top 1% of workers has more than doubled, and the top-earning 0.1% of households now controls the same amount of wealth as the bottom 90%.1,2

The wealth gap is particularly pronounced in racial minorities because of “historical factors dating back to slavery — many of which persist — including [legalized] racial segregation in the pre-civil rights era, pervasive job and housing discrimination, exclusionary city zoning laws, unequal education, and inheritance laws that perpetuate past inequalities,” according to the authors of a report published in the Lancet.3

The number of US households living in extreme poverty — defined as incomes <$2 per person per day — has more than doubled over the past decades to more than 1.6 million.4 Health inequality has increased concurrently with economic inequality. The prevalence of most chronic illnesses, such as heart disease and arthritis, rises predictably as income declines.5 Differences in life expectancy have also widened between wealthy and low-income Americans: the poorest 1% of citizens have a life expectancy 10.1 years and 14.6 years shorter for women and men, respectively, compared with the richest 1%.6

Contributing Factors

Several factors are thought to influence healthcare inequality:

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Uninsurance or underinsurance . Large disparities in access to care in the United States primarily result from a lack of or inadequate insurance among low-income citizens, who comprise the majority of the 27 million Americans who are still uninsured despite the passage of the Affordable Care Act (ACA) (compared with 50 million pre-ACA). “The uninsured are far more likely than the insured to forgo needed medical visits, tests, treatments, and medications because of cost,” the report authors noted. Such cost-related barriers are especially pronounced in Southern states and in uninsured individuals with chronic conditions.

Large disparities in access to care in the United States primarily result from a lack of or inadequate insurance among low-income citizens, who comprise the majority of the 27 million Americans who are still uninsured despite the passage of the Affordable Care Act (ACA) (compared with 50 million pre-ACA). “The uninsured are far more likely than the insured to forgo needed medical visits, tests, treatments, and medications because of cost,” the report authors noted. Such cost-related barriers are especially pronounced in Southern states and in uninsured individuals with chronic conditions. Medicaid . While Medicaid coverage improves access to care and health outcomes, including rates of depression, illness-related financial issues, and mortality, access is still significantly limited, perhaps due to the fact that “specialist care is often unobtainable because the [program] pays low fees to physicians, who are free to turn away Medicaid patients,” according to the report authors.

While Medicaid coverage improves access to care and health outcomes, including rates of depression, illness-related financial issues, and mortality, access is still significantly limited, perhaps due to the fact that “specialist care is often unobtainable because the [program] pays low fees to physicians, who are free to turn away Medicaid patients,” according to the report authors. Private insurance . Even patients with private insurance are affected by access issues as a result of increases in cost-sharing in the form of copayments, deductibles, and narrow physician choices offered by payers. “Predictably, patients’ use of care declines as their cost-sharing obligation rises, and people with the worst health are most likely to cut back on care.” This can backfire, resulting in greater downstream health issues and associated costs. For instance, children with asthma whose insurance plans required higher co-payments were found to be 41% more likely to have an asthma-related hospital admission than those with lower co-payments. 7

Even patients with private insurance are affected by access issues as a result of increases in cost-sharing in the form of copayments, deductibles, and narrow physician choices offered by payers. “Predictably, patients’ use of care declines as their cost-sharing obligation rises, and people with the worst health are most likely to cut back on care.” This can backfire, resulting in greater downstream health issues and associated costs. For instance, children with asthma whose insurance plans required higher co-payments were found to be 41% more likely to have an asthma-related hospital admission than those with lower co-payments. Geographical access. Geography is often another barrier to care, particularly in rural areas where specialty care — and often primary care — is sparsely available. “Many rural and Southern states also have a shortage of adequate family planning resources,” the authors noted. “Texas, for example, has imposed onerous regulations and funding cuts on family planning clinics, causing closure of many and a subsequent increase in unwanted pregnancies.”8 Although women are more likely to be insured and have lower median incomes than men, they still have higher out-of-pocket healthcare costs than men.

Healthcare disparities are especially evident within the realm of mental illness and substance abuse treatment. Although mental health parity is now required by law, enforcement has been challenging, Medicaid programs are exempt from this requirement, and there is a shortage of psychiatric providers in general, particularly in poor and rural areas. “Jails remain the largest so-called inpatient mental health facilities in the USA,” according to the report.

Steep medical bills contribute substantially to household debt and bankruptcy, thereby further increasing the income gap between wealthy and poor. More than half of unpaid debts turned over to collection agencies are medical bills, and 1 in 10 families with difficulties paying medical bills has filed for bankruptcy. Among Americans who struggle to pay medical bills, an estimated 34% were unable to pay for food, housing, or heat, and many secured high-interest loans, had several jobs, or worked overtime.9

While many physicians are advocating for improved healthcare justice in the United States, increased efforts are needed to advocate for care in disadvantaged groups. “The brave cadre of colleagues who face constant threat for delivering abortion services (which are disproportionately needed by poor women) must be supported and augmented, especially as anti-choice politicians now hold sway in Washington, DC” the authors wrote.

In addition, the study recommends that physicians support initiatives similar to the WhiteCoats4BlackLives movement, which decries the structural racism still pervasive in medical institutions and policies, and advocates for reforms that build on rather than repeal ACA gains. “Republicans aspire to roll back the law’s coverage expansions, fully [privatize] Medicare and the VA [Veterans Administration], and give state governments free rein to cut Medicaid — changes that must be resisted to avoid a public health disaster,” they concluded.

Clinical Pain Advisor interviewed co-author David Himmelstein, MD, FACP, professor of public health and health policy at the City University of New York School of Urban Public Health at Hunter College, New York, and lecturer in medicine at Harvard Medical School, Boston, Massachusetts. He offered further insight into these issues, along with what he says is the only solution.

Clinical Pain Advisor: Does the US healthcare system exacerbate income-based disparities, in your opinion, and if so, how?

Dr Himmelstein: There are 2 main ways, one of which is by providing unequal care. That is, poorer individuals have much more difficulty affording and gaining access to care and once they gain access they more often receive poorer quality care. Second, the financing of the healthcare system is extremely regressive; it takes a far larger percentage of income from poorer than from wealthier Americans. As a result, it exacerbates income inequality.

Clinical Pain Advisor: What are believed to be the reasons for the increase in healthcare resources devoted to wealthy Americans?

Dr Himmelstein: As costs have risen and more and more poor and middle-income people have difficulty affording care, they are reducing their utilization of care. Doctors with empty appointment slots and hospitals with empty beds are apparently compensating by delivering more care to the wealthy — a phenomenon called supplier-induced demand. This phenomenon has been well-documented in several circumstances. For instance, for many types of elective or semi-elective surgery, the number of surgeons available is a strong predictor of the number of operations performed.

When Canada implemented its national health insurance program, which gave everyone complete coverage for doctor visits, the total number of doctor visits did not go up, but poorer and sicker Canadians saw the doctor more often, while wealthier Canadians had somewhat fewer visits. In a similar fashion, when Medicare was first implemented the number of doctor visits did not go up, but visits by the poor increased while those by wealthier Americans fell.

Clinical Pain Advisor: What are the proposed solutions to this issue of disparity in healthcare?

Dr Himmelstein: The only viable solution is tax-funded national health insurance.

Drs Himmelstein and Woolhandler, two of the authors of the Lancet report, founded Physicians for a National Health Program, which advocates for a single-payer national health insurance system in the U.S., and served as unpaid advisors to Senator Bernie Sanders during his presidential campaign. Dr Dickman declares no conflicts of interest.

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