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Select a complex sentence from one of the assigned readings on health and wealth and complete the following:Post the original sentence as a quoteRevise the sentence to make it more concise. Be sure to indicate your revisions in bold type.
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Income and Health Initiative: brief ONE
How Are Income and Wealth
Linked to Health and Longevity?
APRIL 2015
Steven H. Woolf
Laudan Aron
Lisa Dubay
VCU Center on Society and Health
Urban Institute
Urban Institute
Sarah M. Simon
Emily Zimmerman
Kim X. Luk
VCU Center on Society and Health
VCU Center on Society and Health
VCU Center on Society and Health
Center on
Society
and Health
The Gradient between Economic
Wellbeing and Health
The greater one’s income, the lower one’s likelihood of disease and premature death.1 Studies show that
Americans at all income levels are less healthy than those with incomes higher than their own.2 Not only
is income (the earnings and other money acquired each year) associated with better health, but wealth
(net worth and assets) affects health as well.3
Though it is easy to imagine how health is tied to income for the very poor or the very rich, the relationship
between income and health is a gradient: they are connected step-wise at every level of the economic ladder.
Middle-class Americans are healthier than those living in or near poverty, but they are less healthy than
the upper class. Even wealthy Americans are less healthy than those Americans with higher incomes.
Income is a driving force behind the striking health disparities that many minorities experience. In fact,
although blacks and Hispanics have higher rates of disease than non-Hispanic whites, these differences
are “dwarfed by the disparities identified between high- and low-income populations within each racial/
ethnic group.” 4 That is, higher-income blacks, Hispanics, and Native Americans have better health than
members of their groups with less income, and this income gradient appears to be more strongly tied to
health than their race or ethnicity.
People with Lower Incomes Report Poorer
Health and Have a Higher Risk of Disease
Poor adults are almost five times as likely to report being in fair or poor health as adults with family
incomes at or above 400 percent of the federal poverty level, or FPL, (in 2014, the FPL was $23,850 for
a family of four) (figure 1), and they are more than three times as likely to have activity limitations due to
chronic illness.5 Low-income American adults also have higher rates of heart disease, diabetes, stroke, and
other chronic disorders than wealthier Americans (table 1).
Figure 1. Self-Report of Fair or Poor Health, by Income, 2011
Percentage of adults
22.8%
12.9%
9.4%
Less than $35,000
$35,000–49,999
$50,000–74,999
7.0%
$75,000–99,999
5.6%
$100,000 or more
Annual family income
Source: Schiller, J. S., J. W. Lucas, and J. A. Peregoy. 2012. “Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2011.”
Vital and Health Statistics 10 (256): Table 21. http://www.cdc.gov/nchs/data/series/sr_10/sr10_256.pdf
How are income and wealth linked to health and longevity?
1
Infant mortality and children’s health are also strongly linked to family income and maternal education.2
Rates of low birth weight are highest among infants born to low-income mothers.6,7 Children in poor
families are approximately four times as likely to be in poor or fair health as children in families with
incomes at or above 400 percent of the FPL.2 Lower-income children experience higher rates of asthma,
heart conditions, hearing problems, digestive disorders, and elevated blood lead levels.8,9 In 2006–08, the
prevalence of asthma was 8.2 percent among nonpoor children but 11.7 percent among poor children and
23.3 percent among poor Hispanic children.10 Poor children also have more risk factors for disease,
such as childhood obesity, which is a strong predictor of obesity as an adult.
Table 1. Prevalence of Diseases, by Income, 2011 (percent of adults)
Annual family income
Less than
$35,000–
$50,000–
$75,000–
$100,000
$35,000
49,999
74,999
99,999
or more
Coronary heart disease
8.1
6.5
6.3
5.3
4.9
Stroke
3.9
2.5
2.3
1.8
1.6
Emphysema
3.2
2.5
1.4
1.0
0.8
Chronic bronchitis
6.3
4.0
4.4
2.2
2.4
Diabetes
11.0
10.4
8.3
5.6
5.9
Ulcers
8.7
6.7
6.5
4.7
4.4
Kidney disease
3.0
1.9
1.3
0.9
0.9
Liver disease
2.0
1.6
1.0
0.6
0.7
Chronic arthritis
33.4
30.3
27.9
27.4
24.4
Hearing trouble
17.2
16.0
16.0
16.2
12.4
Vision trouble
12.7
9.8
7.5
5.7
6.6
No teeth
11.6
7.8
5.5
4.2
4.1
Disease or illness
Source: J. S., Schiller, J. W. Lucas, and J. A. Peregoy, “Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2011.”
Vital and Health Statistics 10, no. 256 (2012): 1–207, tables 1, 4, 8, and 12. http://www.cdc.gov/nchs/data/series/sr_10/sr10_256.pdf.
The reported higher rates of disease among low-income Americans are accompanied by higher rates of risk
factors. In 2011, smoking was reported by one out of four (27.3 percent) adults from families who earn less
than $35,000 a year, three times the rate of those from families who earn $100,000 a year or more
(9.2 percent).11 Obesity rates were also higher (31.9 and 21.2 percent, respectively),11 in part because of lower
2
levels of physical activity. In 2011, the proportion of adults who reported getting recommended levels of
aerobic exercise was 36.1 percent for those living in poverty compared with 60.1 percent for those with
incomes at least four times higher than the FPL.1
Income is also associated with mental health. Compared with people from families who earn more than
$100,000 a year, those with family incomes below $35,000 a year are four times more likely to report
being nervous and five times more likely to report sadness “all or most of the time” (figure 2).11
Somatic complaints (i.e., the pain and other physical ailments that people experience due to stress and
depression) also occur more commonly among people with less income.
Figure 2. Feelings of Worthlessness, Hopelessness, and Sadness All or Most of the Time, by Income, 2011
Percentage of adults
Sadness
Hopelessness
Worthlessness
6.4%
4.6%
3.8%
3.2%
2.3%
Less than $35,000
1.9%
$35,000–49,999
2.3%
1.5%
1.1%
$50,000–74,999
1.3%
1.2%
0.6% 0.6%
0.5% 0.6%
$75,000–99,999
$100,000 or more
Annual family income
Source: J. S., Schiller, J. W. Lucas, and J. A. Peregoy, “Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2011.”
Vital and Health Statistics 10, no. 256 (2012): 1–207, table 14. http://www.cdc.gov/nchs/data/series/sr_10/sr10_256.pdf.
People with Lower Incomes Live Shorter Lives
At age 25, Americans in the highest income group can expect to live more than six years longer than their
poor counterparts (figure 3).12 The Social Security Administration reports that retirees at age 65 are living
longer, but since the 1970s those with earnings in the top half of the income distribution have seen their life
expectancy increase by more (6.0 years) than those in the bottom half (1.3 years).13
How are income and wealth linked to health and longevity?
3
Figure 3. Life Expectancy, by Income, 1988–98
Years an adult can expect to live after age 25
49.2
Less than 100%
51.4
101–200%
53.8
201–400%
55.7
More than 400%
Family income (percent of FPL)
Source: Paula Braveman, Susan Egerter, and Colleen Barclay, “Income, Wealth and Health,” Exploring the Social Determinants of Health,
(Princeton, NJ: Robert Wood Johnson Foundation): 2011.
Note: FPL = federal poverty level.
These income-based differences in life expectancy can also be seen across communities. For example,
Virginia’s Fairfax County, one of the richest counties in the country, and West Virginia’s McDowell County,
one of the poorest, are separated by just 350 miles; however, the difference in life expectancy between the
two counties is vast. In Fairfax, “men have an average life expectancy of 82 years and women, 85, about the
same as in Sweden.”14 By contrast, the average male and female estimates for life expectancy in McDowell
County are 64 and 73 years, respectively, about the same as in Iraq.14
How Income and Wealth Might Influence Health
To some extent, income and wealth directly support better health because wealthier people can afford
the resources that protect and improve health. In contrast to many low-income people, they tend to have
jobs that are more stable and flexible; provide good benefits, like paid leave, health insurance, and worksite
wellness programs; and have fewer occupational hazards. More affluent people have more disposable
income and can more easily afford medical care and a healthy lifestyle—benefits that also extend to
their children.
Lower-Income Americans Are Less Able to Afford
Health Care Services and Health Insurance
People with low incomes tend to have more restricted access to medical care, are more likely to be
uninsured or underinsured, and face greater financial barriers to affording deductibles, copayments, and
4
the costs of medicines and other health care expenses. Conditions may change under the Affordable Care
Act, but as of 2011 the probability of being uninsured before age 65 was 28.4 percent for those living in
poverty, 16.5 percent for those with incomes two to three times the FPL, and 5.2 percent for those with
incomes four or more times the FPL.15
Partly because of reduced access to care and reduced affordability, low-income patients are less likely to
receive recommended health care services, such as cancer screening tests and immunizations. For example,
in 2012 the proportion of adults ages 50 to 75 who reported never having been screened for colorectal
cancer was 19.5 percent for those with annual household incomes of $75,000 or more but 42.5 percent for
those with incomes below $15,000.16
In 2011, almost one-quarter (23.3 percent) of adults with family incomes under $35,000 per year had no
usual place of medical care, compared with 6.0 percent of those with incomes of $100,000 or higher.11
Similarly, 22.6 percent reported not having seen a dentist in more than five years, compared with 4.3
percent of adults with family incomes over $100,000.11
Families with Greater Resources Can Afford Healthy
Lifestyles and Experience Place-Based Health Benefits
More affluent people can more easily afford regular and nutritious meals, which tend to be more expensive
and less convenient than less nutritious, calorie-dense, high-carbohydrate options and fast foods. People on
low incomes face higher rates of food insecurity. Their difficult living circumstances often preclude active
recreational opportunities for regular exercise, and the cost of gym memberships or exercise equipment
is often prohibitive. They may also face financial and other barriers to obtaining assistance with lifestyle
changes, such as smoking cessation or assistance with alcohol and drug dependence.
People with higher incomes are more likely to experience place-based health benefits, meaning that their
health is positively influenced by the conditions and assets in their living environment.12 In other words,
even after adjusting for income and other attributes of individuals and households, health benefits appear to
be associated with where people reside.17 Ellen and Turner (1997) identified six ways in which neighborhood
conditions can influence the health of individuals: (1) quality of local services, (2) socialization, (3) peer
influences, (4) social networks, (5) exposure to crime and violence, and (6) physical distance and isolation.
Low-income neighborhoods and areas of concentrated poverty tend to expose their residents to higher rates
of unemployment, crime, adolescent delinquency, social and physical disorder, and residential mobility.18
The socioeconomic status of individuals and neighborhoods are intertwined with individual and population
health because the local economy determines access to jobs, commerce, schools, and other resources that
enable families to enjoy economic success and place-based health benefits. For example, one study found
that “healthy adults residing in socioeconomically deprived neighborhoods died at a higher rate than did
people in relatively less deprived areas, even after accounting for individual-level socioeconomic status,
lifestyle practices, and medical history.”19 Smoking, diabetes, and other conditions are more common for
people living in poor neighborhoods, independent of their income.20,21
How are income and wealth linked to health and longevity?
5
Population health is influenced not only by the economic well-being of individuals and households but also
by the civic and economic vitality of their communities. People unable to afford to live in healthier, more
desirable areas often struggle with challenges related to a variety of community-level health-related factors:
• Access to healthy food. Residents of low-resource neighborhoods often have limited access to sources
of nutritious food,22 such as supermarkets that sell fresh produce and other healthful food options.23
They are more likely to live in neighborhoods with food deserts;24 an overconcentration of fast-food
outlets,25 convenience stores, corner stores, bodegas, and liquor stores; and a shortage of restaurants
that offer healthful food choices23 and menu labeling.26
• Built environment. Low-income communities tend to have limited access to green space, recreational
programs, and facilities for regular exercise and active living.27 Their neighborhoods are often less
conducive to walking or cycling to school, work, or shopping.
• Advertising. Low-income and minority communities are more frequently targets for advertising of
tobacco, alcohol, and high-calorie foods, often targeted to youth.
• Housing. People with limited resources experience higher rates of inadequate and unstable housing
(and homelessness) and exposure to indoor pollutants (e.g., lead-based paint, asbestos, and dust mites).28
They often experience barriers to moving to a better neighborhood with healthier housing stock.
• Transportation. Public transportation is often inadequate to enable residents to commute to
employment, to find a better job, or to reach a supermarket, a reliable childcare provider, or health
care services.29
• School systems. People with low incomes are more likely to live in poorer neighborhoods with
a weaker tax base, thus reducing local resources that support public schools and social services.30
Cash-strapped schools in low-income neighborhoods may have inferior resources and
deteriorated buildings.27
• Jobs and health care. Low-resource neighborhoods often face a shortage of employment
opportunities, as well as primary care providers and high-quality clinical facilities.31
• Environmental pollution. Low-income residents are less likely to be able to afford living in
neighborhoods that are free of pollutants32 and may of necessity live near busy highways with vehicle
emissions, factories with billowing smokestacks and water emissions, bus depots, and other sources
of air and water pollution.33
• Disinvestment. Low-income residential neighborhoods reflect urban design legacies that discourage
pedestrian activity and such practices as redlining, which served to isolate and segregate minority
populations. Entrenched patterns reflecting long-standing disadvantage often perpetuate cycles of
socioeconomic failure and an inability for low-income neighborhoods to recover. Public policies have
historically led to disinvestment in these neighborhoods, causing persistent segregation, fewer economic
opportunities, and increasing crime.34
6
Other Reasons for Poor Health Among
Low-Income Americans
Income and wealth are part of a complex web of social and economic conditions that affect health
(and each other) over a lifetime.35 These conditions include education, employment, family structure
(e.g., single motherhood), neighborhood characteristics, and social policies, as well as culture, health beliefs,
and country of origin.36 Educational achievement is an especially strong predictor of health independent
of income.37 There is also evidence that when people are exposed to economic disadvantage—especially at
critical developmental stages of life—and to other harmful life conditions they become more vulnerable to
disease processes and experience harmful physiological reactions to toxins in their environment.38
The stress associated with financial adversity is believed to have harmful biological effects on the body.39
Stress is thought to affect hormones and the health of the immune system (a phenomenon called allostatic
load), causing damage to organs and increasing the risk of disease over time.
Health and income affect each other in both directions: not only does higher income facilitate better health,
but poor health and disabilities can make it harder for someone to succeed in school or to secure and retain
a high-paying job.40 Scientists call this phenomenon reverse causality or selection effects. The role of reverse
causality is not entirely clear, as much of the evidence linking income and health consists of studies that
show an association but are not designed to prove the direction of causal relationships. There is, however, a
small but more compelling body of prospective evidence about the protective effects of income on health.41
The Interplay of Income and Health
OVER THE LIFE COURSE
The health and survival of children are tied to the income of their parents.2 Early life experiences,
the social and economic status of our parents, and the social and physical environments in our childhood
all matter greatly when it comes to shaping health and economic well-being throughout our own and our
children’s lives. Exposure to unfavorable living conditions and instability in early childhood, beginning as
early as the womb,42 can have a variety of negative effects on a person’s health and economic future.43-46
Children exposed to social exclusion and bias, persistent poverty, and trauma can experience toxic stress
and harmful changes in the architecture of the developing brain that affect cognition, behavioral regulation,
and executive function.47-52 Low-income children in the United States face a variety of challenges at school:
for example, they are assigned disproportionately to “the most inadequately funded schools with the largest
class sizes and lowest-paid teachers.”27
The socioeconomic conditions experienced by children continue to affect their health status
throughout adulthood.53,54 Long-term studies have shown that children with greater exposure to adverse
childhood events (ACEs) are more likely to develop unhealthy behaviors as adults (e.g., smoking, physical
inactivity, alcoholism, drug abuse, multiple sexual partners) and to have a history not only of adverse
psychological outcomes (e.g., depression, suicidal ideation) but increased risk of physical illnesses.55
In a classic study, adults who reported four or more ACE categories were twice as likely to have heart
How are income and wealth linked to health and longevity?
7
disease, cancer, stroke, and diabetes and four times as likely to have chronic lung disease.50 All the factors
(and the relationships among them) that account for this higher risk are not fully understood; the outcomes
experienced by victims of ACEs, for example, may result from mediating factors such as childhood poverty
and other variables.
Along with the harmful physiological changes induced by stress, ACEs and other difficult early life
conditions can lead to dysfunctional coping skills that result in harmful or risky behaviors, illness, and
injury in adolescence. These negative outcomes can stifle later economic success, which means that some
of the links between income and health may actually reflect common factors earlier in life.56-58 Liu and
colleagues reported that the unemployment rate was twice as high (13.2 percent) among adults exposed as
children to four or more ACEs as among those with no exposure (6.5 percent). Even aft …
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