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The Gross Inequality of Death in America

The richest Americans live 10-15 years longer than the poorest Americans. It will take a lot more than Medicare for All to close the gap.

Mario Tama/Getty Images

One of the most disquieting facts about life in the United States today is that the richest American men live 15 years longer than the poorest men, while for women it’s 10 years. Put a different way, the life expectancy gap between rich and poor in the U.S. is wider than the gap between the average American and the average Yemeni or Ethiopian.

This gap is only getting wider. According to a report by the Health Inequality Project, from 2001-2014, the richest Americans gained approximately three years in life expectancy while the poorest Americans experienced no gains. A three-year difference in life expectancy may seem trivial, but, as the report’s authors note, this gain in lifespan is the equivalent of curing cancer for only the rich. Going back further, the numbers only get worse: The richest American males gained six years in life expectancy from 1980 to 2010, while outcomes for the poorest men remained stagnant.

These facts would seem to justify the Democratic Party’s widespread support for universal health care. Presidential candidates including Bernie Sanders, Elizabeth Warren, Cory Booker, Kamala Harris, and Julian Castro support some form of Medicare for All, and many of the candidates who haven’t fully endorsed MFA have gone to all lengths to convince voters—sometimes unconvincingly—that their plans will guarantee low-cost universal coverage.

When it comes to the health-wealth gap, though, Medicare for All may not be the silver bullet that progressives hope for. Most evidence suggests that while universal health care is a necessary step to closing this gap, it is nowhere near enough. That’s because there are two other major factors that cause the rich to live so much longer than the poor.     

If the health-wealth gap is merely the product of access to quality health care, then the gap should largely disappear when health care access is equalized across society. But that’s not the case in countries that already have universal health care coverage. In France, which has one of the best and most extensive health care systems in the world, the health-wealth gap is about 11 years. Even in the United Kingdom, home to the most robust single payer health care system on the planet, the rich live about 9 years longer than the poor.

The researchers at the Health Inequality Project found a similar result when comparing states within the U.S. “Differences in life expectancy among the poor,” their final report stated, “are not strongly associated with differences in access to health care.”

The health-wealth gap also exists for diseases that have nothing to do with health care access, namely juvenile diabetes and rheumatoid arthritis. Furthermore, the recent fall in life expectancy in the U.S. has been driven by what Princeton economists Anne Case and Angus Deaton have dubbed “deaths of despair”—namely, suicides and drug overdoses—which have little to do with health care access and disproportionately impact the poor nonetheless. (These conditions do, however, have much to do with mental health and drug addiction services.)

This health-wealth gap also remains when taking behavior into account—for example, the fact that poor people tend to be heavier smokers and drinkers. The famous Whitehall studies of the British Civil Service led by epidemiologist Michael Marmot found that only about one-third of the health-wealth gap can be explained by “risk” factors such as smoking, alcohol consumption, and reliance on fast food. When you add in “protective” factors such as access to health care or workout facilities, the number still represents less than half of the total gap.

So, what is responsible for the majority of the health-wealth gap? Stanford neuroscientist Robert Sapolsky, who has been speaking and writing on this question for decades, offers a simple answer: poverty itself. Or, as Sapolsky puts it, “the psychosocial impact of being poor.”

Drawing on research from neuroscience, psychology, and neurobiology, Sapolsky found a powerful link between poverty, chronic stress, and severe health outcomes. As our body’s adaptive response to external threats, short-term stress can be a good thing: It prompts the fight-or-flight response that can help us survive dangerous situations. However, human beings uniquely experience what is known as “chronic stress”: prolonged psychosocial stress that can last for months or even years.

Chronic stress can literally kill us. It increases the risk and severity of diseases like type 2 diabetes and gastrointestinal disorders, impairs the growth of children, suppresses our immune system (rendering us less able to fight even basic sicknesses), and increases our likelihood of becoming depressed or addicted.

While all humans experience stress, Sapolsky points out that the experience of chronic stress is not evenly distributed across society. An extensive biomedical literature indicates that people are more likely to experience stress-related diseases when they lack control over, and social support for dealing with, stressful conditions. The poor disproportionately face such conditions.

A life of poverty can mean a life of constant stress. The poor have little control over their work schedules or wages. (In the Whitehall studies, one’s level of control in the workplace, even for workers within the same organization, accounted for one-half of health disparities.) They fear suddenly losing their job and being unable to pay the bills. They despair over their own future, and how to give their children a better life. They are exhausted and socially isolated by second or third jobs, long commutes, and weekend shifts. They lack the means to take much-needed time off or pay for relaxing hobbies. And often their social support systems are decimated by incarceration, addiction, and depression.

It’s no wonder that the poor have consistently worse health outcomes. Their brains are working overtime all the time.

Yet poverty and its antecedents may only be the beginning. As Sapolsky notes, recent research indicates that living in “poverty amidst plenty”—inequality—is also an important part of the health-wealth equation. For example, Psychologist Nancy Adler has demonstrated that how people rate how they are doing, relative to others, is at least as predictive of health or illness as are any objective measures such as actual income level, and research by epidemiologists Richard Wilkinson and Kate Pickett has shown that by just about every health indicator—infant mortality, overall life expectancy, obesity, you name it— inequality can be even worse than poverty. In the Whitehall studies, Marmot found a fourfold difference in rates of cardiac disease mortality between the lowest and highest rungs of the British Civil Service, despite the fact they were all paid a living wage.

What this research shows is that health outcomes are not simply a matter of access to healthcare: Poverty and inequality are themselves matters of life and death. Policies that provide a basic income, institute a living wage, eliminate college debt, guarantee affordable housing, and give workers collective bargaining power are thus equally important for closing the egregious gap in life expectancy between America’s rich and poor. If the health of all Americans is a priority for the Democratic Party, candidates must be as serious about lifting people out of poverty, increasing workers’ control, and reducing income inequality as they are about implementing universal health care.