Exploring Human Potential

The Presidential Debate: Race, Class, and Health

Posted on | August 13, 2012 | No Comments

Mike Magee

With the selection of Paul Ryan by Governor Romney, pundits are predicting a real ideologic battle come November. The choice we’ll be debating will likely be about what kind of America we want, and will certainly deal with race, class and health.

What will be the quality of the debate? Hopefully, well-informed. Let’s have a look.

Fifteen years ago, the U.S. health care system received a shot across the bow from the World Health Organization. The W.H.O. had been fast at work on a comparative study of national health systems. The study considered five standards – overall level of population health, health inequalities, overall health system responsiveness, distribution of responsiveness, and distribution of financial burden. Surprising to many U.S. leaders, our national system was ranked a dismal 37th, primarily because we scored comparatively low in distribution of resources and in distribution of financial burden.(1) Translation: Class disparities.

The report seemed to reveal the issue of feast or famine in U.S. health. The feast? According to a 2002 Institute of Medicine report, Americans today, compared to Americans in 1900, “are healthier, live longer, and enjoy lives that are less likely to be marked by injuries, ill health or premature death.”(2) The famine? As stated by health policy experts Stephen Isaacs and Steven Schroeder in the New England Journal of Medicine in 2004, “Any celebration of these victories must be tempered by the realization that these gains are not shared fairly by all members of our society.”(3)

The most recent U.S. response by the Obama administration has been to critically explore how best to expand health insurance while reversing the decade long trend toward accelerating income disparities. Yet, studying disparities isn’t quite as straightforward as it may sound.  As Isaacs and Schroeder note, “Race and class are both independently associated with health status, although it is often difficult to disentangle the individual effects of the two factors.”(3)

A few simple numbers illustrate this point. Whites have a median net worth in the United States that is 10 times greater than blacks.(4) While 11 percent of whites live below the poverty line, 27 percent of blacks struggle with poverty.(5) The life expectancy of blacks is seven years less than that of whites. And blacks suffer higher rates of cardiovascular disease, diabetes, hypertension, infant mortalities, homicides, and a variety of cancers.(6)

It’s clear that prejudice and discrimination, the hallmarks of racism, impact the health of minorities in America, but it is becoming increasingly obvious that low socioeconomic status, which is often a byproduct of racial discrimination, also has a significant impact on health. Looking at the number of deaths per 100,000 person-years in adult men with incomes under $10,000 per year, blacks have 21 percent more deaths than whites. This difference declines to 4 percent for those with incomes from $15,000 to $25,000. But when you turn the numbers sideways, comparing whites with incomes below $10,000 with whites with incomes of $15,000 to $25,000 per year, the higher income group has 240 percent fewer deaths. A similar comparison among blacks shows 275 percent fewer deaths among those with higher incomes.(3)

Besides income, other socioeconomic issues intersect with race to profoundly alter health.(7) For example, people without a high school diploma are three times more likely to smoke than college graduates, and they’re three times less likely to exercise.(8,9) And clerical civil servants in Britain have death rates from cardiovascular disease that exceed deaths rates of their administrators by 300 percent.(10)

Income, education, and employment are relatively blunt measures. But even these measures, and their relationship to a population’s health, have not traditionally been captured in U.S. health policy research efforts. The United States does not systematically collect mortality and morbidity data stratified by social class. Death certificates, for example, note race, but until recently did not capture employment, income, or education level.(3)

Experts debate which of these class factors primarily impacts health. Is it education, with its associated access to better jobs, embedded values, problem-solving skills and effect on self-esteem? Is it higher income, which allows for basic needs to be met, secures better neighborhoods and schools, and allows better access to services? Or is it employment, especially jobs that provide decent working conditions, security, health insurance, and moderate stress?

Likely, it’s all of the above, playing off each other and not addressable solely through traditional health programming. But we know that some factors are associated with low socioeconomic status and poor health, such as poor nutrition, increased smoking, decreased exercise, increased stress and fear, unsafe neighborhoods with high crime levels, substandard housing, inaccessible and expensive services, environmental hazards, and poor schools.(3)

So it is increasingly clear that significant investment in the short and medium term to address socioeconomic issues (the Obama administration’s stimulus package and emphasis on stabilizing and expanding the middle class) could favorably impact health and health care costs over the long term. This favorable impact is likely because education, transportation, recreation, housing and tax policy all impact health policy. As for Obamacare, studies have shown that expanding access to care has the potential alone to decrease premature deaths by 15%.(11)

Most of the remaining potential benefit is embedded in the expansion of healthy behaviors within individuals, families, and communities. The keys that unlock those doors are opportunity, security, and confidence in the future.

Ready for a debate? For Health Commentary, I’m Mike Magee.

1. World Health Organization Assesses the World’s Health Systems [news release on World Health Organization Web site].
2. Committee on Assuring the Health of the Public in the 21st Century, Institute of Medicine. 2002. The Future of the Public’s Health in the 21st Century. Available at:
3. Isaacs SL, Schroeder SA. Class – the ignored determinant of the nation’s health. NEJM 2004;351;1137-42.
4. Williams DR. Race and health: trends and policy implications. In: Auerbach JA, Krimgold BD, eds. Income, socioeconomic status, and health: exploring the relationships. Washington, D.C.: National Policy Association, 2001:70.
5. U.S. Census Bureau. Poverty in the United States, 1997. Available at:
6. Thomas SB, Quinn SC. Eliminating health disparities. In: Braithwaite RL, Taylor SE, eds. Health issues in the black community. San Francisco: Jossey-Bass, 2001:543-63.
7. McDonough P, Duncan GJ, Williams DR, House J. Income dynamics and adult mortality in the United States, 1972 through 1989. Am J Public Health 1997;87:1476-83.
8. Health, United States. Hyattsville, Md.: National Center for Health Statistics, 2002:198. (DHHS publication no. (PHS) 2002-1232.)
9. Pratt M, Macera CA, Blanton C. Levels of physical activity and inactivity in children and adults in the United States: current evidence and research issues. Med Sci Sports Exerc 1999;31:Suppl:S527-S533.
10. Davey Smith G, Blane D, Bartley M. Explanations for socio-economic differentials in mortality: evidence from Britain and elsewhere. Eur J Public Health 1994;4:131-44.
11. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93.


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