Lancet series puts spotlight on health inequity in the U.S.

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Poverty and institutional racism are major barriers to care for minority and poor Americans, according to a new series from The Lancet.

Societal issues in the U.S., including systemic racism, poverty and mass incarceration, contribute to health inequity, a new series of studies has found.

The Lancet released a five-part look at health inequity in the U.S., titled the “United States of Health,” and researchers found that institutional racism, the increasing income gap and high rates of incarceration are all factors that make it harder for minorities and the poor to access healthcare. And the healthcare system, as it is financially structured today, only makes this problem worse, the researchers concluded.

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The researchers called for wide-ranging initiatives that tackle these issues and for health reform that pushes the U.S. healthcare system toward a single-payer model. In a letter opening the series, Sen. Bernie Sanders, I-Vt., wrote that healthcare is “not a commodity” that should not be used to line the pockets of stockholders and corporate officials.

“The USA has the most expensive, bureaucratic, wasteful and ineffective healthcare system in the world,” Sanders wrote. “Medicare-for-all would change that by eliminating private health insurers' profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions in medical costs."

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Poor Americans have made limited gains in life expectancy over the past 15 years, researchers found. Since 2001, the poorest 5% have not seen their survival rates increase at all, while while middle- and high-income people have seen their life expectancy increase by two years. The richest 1% of Americans live between 10 and 15 years longer than those who are among the poorest 1%.

Economic insecurity is a key factor in some of today’s biggest public health crises, including the opioid epidemic and increasing rates of obesity, study author Jacob Bor, Sc.D., assistant professor at the Boston University School of Public Health, said in announcement. But despite their increasing health concerns, it is becoming increasingly hard for Americans in poverty to pay for healthcare, creating a “health-poverty trap,” Bor said.

Poor Americans are also the most likely to be uninsured. Though the Affordable Care Act has made strides toward decreasing the number of people without insurance, a lack of options in ACA exchanges, particularly in states that did not expand Medicaid, leaves many poorer people in the U.S. with few avenues to get health insurance, researchers found. In 2015, for instance, about a quarter of poor Americans were uninsured, compared with just 7.6% of people with middle or high incomes.

Minority groups are also hit hard by societal barriers that lead to health inequity, and research reflects poorer outcomes—for instance, infant mortality rates for black populations are twice those for white ones, according to the study. Structural racism relegates many black Americans to neighborhoods with poor housing options, high rates of crime and air pollution. These neighborhoods may also be neglected by public health officials, worsening the problems, researchers found.

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“Structural racism refers to all the ways in which systems foster inequitable outcomes, whether in housing, education, employment, media, healthcare or the criminal justice system,” Mary T. Bassett, M.D., commissioner of the New York City Department of Health and Hygiene, said in the announcement. “All have profound effects on health. If we don't address structural racism, health inequities will persist."

Community health programs that improve access to healthcare and other socioeconomic needs like housing and better training for future health professionals are possible solutions. Reducing incarceration rates and taking another look at sentencing laws can also reduce health disparities that minorities disproportionately face, according to the study.

The United States has the largest prison population in the world, by a wide margin. Current and former inmates have high rates of chronic conditions like HIV, hepatitis C, hypertension and diabetes, and are at higher risk for substance abuse and mental health disorders as well, according to the series. People on probation or who were recently paroled also face higher mortality rates.

If mass incarceration policies had not taken effect and incarceration rates remained at mid-1980s levels, life expectancy would be more than 50% higher by 2005 in the U.S., the researchers estimated.


“Although a series about health published in a medical journal may seem far removed from the political arena where much of the decision making about how to address these factors lies, the message of this collection of papers transcends that distance,” The Lancet wrote in its introduction to the series. “Whether that change takes the form of a single-payer option, it is no radical statement to say that Americans deserve better and, most importantly, the time for action has arrived.”