Lately, it has felt like the debate over Obamacare has masked some of the bigger questions swirling around the U.S. health system. Obamacare is important, yes, but America’s issues on this front run much, much deeper than the presence or absence of that one law. After all, despite the fact that the U.S. is the richest and most powerful country in the world, by many metrics it has the worst health-care system of any wealthy, developed nation — particularly with regard to how marginalized people fare.
So it was interesting to dive into “America: equity and equality in health,” a series published last week by the Lancet. As the name suggests, the series’ five articles dig into the fraught nature of health care in the U.S. The articles cover a lot of ground, ranging from the effects of mass incarceration to the latest long-term trends in health outcomes, and all are worth reading. But here are three nuggets that stood out:
The public-health situation is so bad for black men in the U.S. that they often get better health care in prison than they do outside it. In their paper “Mass incarceration, public health, and widening inequality in the USA,” Christopher Wildeman and Emily A. Wang note that “[b]eing incarcerated might, paradoxically, decrease mortality and physical morbidity in the short term for some groups”:
Black male prisoners, for instance, have far lower mortality than similarly aged black men in the general population. Researchers speculate that the protective effects of current imprisonment for this group might be driven by a decreased risk of death by violence or accidents, reduced access to illicit drugs and alcohol, and improved health-care access, although the mechanisms are debated. However, the decreased mortality for black male prisoners does not hold for other subpopulations of prisoners. …
[W]e note that prisons and jails are some of the only places in the USA where health care is guaranteed by law (although the often-dramatic variation in the quality of health care in correctional facilities undermines the notion that this mandate has been met). In 1976, the U.S. Supreme Court ruled in Estelle v Gamble that failure to provide basic health care in correctional facilities violated the constitutional prohibition against cruel and unusual punishment. That ruling mandated that prisons and jails provide acute care services, but, as the prison population has aged, prison health-care services have had to provide increased care for chronic diseases as well.
It’s important not to be glib about this finding — incarceration has a devastating effect on both prisoners themselves and their families and neighborhoods. But it’s striking sign of societal failure that the public-health situation for black men in the U.S. is so bad that they often get better care when they’re locked up. It’s also interesting that SCOTUS ruled that prisoners have a human right to health care; outside of prison, of course, there’s no such guarantee, as the wide spread of crowdfunding appeals for health issues have shown. Plenty of people simply can’t afford the health care they need to stay alive, or will go completely bankrupt if they do pay for it.
The increasingly winner-take-all nature of American life can help explain many health disparities. In “Population health in an era of rising income inequality: USA, 1980–2015,” Jacob Bor, Gregory H. Cohen, and Sandro Galea explain that rising income inequality has brought with it rising disparities in health outcomes. Part of this has to do with the startling mortality rates among middle-aged white people, particularly those without a college education, which in turn can be tied to the opioid crisis and the broader helplessness epidemic ravaging a big swath of the country.
But that isn’t the whole story; another important aspect of many increasing health disparities has to do with what privileged people do have access to. The researchers explain that “an exclusive focus on individual-level behavior as a mechanism would miss the larger structural factors that might be driving these trends.” They then go on to list some other factors, and one that jumps out is “differential adoption of technological innovations in medicine as well as nonmedical health inputs (e.g., information about complex health risks and preventive behaviors).” In other words, there is a constant drumbeat of steady medical progress — every day we know a little bit more, have better tools, and can better inform people about which behaviors to adopt and avoid. It’s just that a large and growing swath of the population is cut off from all these benefits. That can partly explain the massive gap in medical outcomes between those at the top and those at the bottom.
Doctors need better and more comprehensive education when it comes to the question of racial prejudice in health care. A fair amount of research has examined the question of disparities in the medical care given to patients of different races. There have been some disturbing findings: Black patients, for example, are often seen as better able to tolerate pain than white patients are, and are therefore less likely to be prescribed painkillers that could significantly ameliorate their suffering. And there are, of course, massive, structural discrepancies in who gets access to which sort of care.
It’s increasingly common for med school to include some sort of material about race, writes a team lead by Zinzi D. Bailey in “Structural racism and health inequities in the USA: evidence and interventions,” but such curricula often fall short:
The standard practice for teaching about race and health in medical and public health schools is one in which race is often discussed, but conversations about racism are sidelined, with scant hours (if any) devoted to social epidemiologists, medical anthropologists, social scientists, or historians who focus on racism and health. Few scientific and medical textbooks include discussions of how racism affects the conceptualization of race or an analysis of racial inequality in relation to health and other outcomes. Although many medical schools now include diversity training and provide instruction on cultural competency, such instruction is often brief (and sometimes delivered online). Moreover, the programs typically focus on individual responsibility to counteract interpersonal discrimination; the goal is for individuals to increase their sensitivity to, and knowledge about, other racial/ethnic groups. The emphasis is therefore on “others,” in a way that could inadvertently contribute to racial stereotyping, as opposed to critical self-reflection about the participants’ positions in their societies’ race relations.
Taking a broader view of racial discrepancies in health care isn’t easy, argue the researchers, but it’s important: “Tying interactions between patients and health-care providers to population-level inequalities requires skilled instruction and considerable time, far beyond that patched together for short training courses in cultural competency.” At a time when inequality is skyrocketing, much of it driven by racial discrepancies, it’s hard to argue against the idea that such programming is important.