Life expectancy, socialism, and the determinants of health

“Socialism,”writes Washington Post columnist Kathleen Parker on February 9, “has always appealed to the young, the cure for which isn’t age but responsibility. This usually comes in the form of taxes and children, both of which involve working and sacrificing for the benefit of others, the extent of which forms the axis upon which all politics turns.” Parker is discussing the brouhaha around comments about the need for women to support Hillary Clinton’s presidential bid, particularly those by Gloria Steinem that young women are supporting Bernie Sanders because, essentially, that’s where the boys are. Her logic seems a little contradictory to me, because socialism is all about being part of a society that we are all in together, where we work and sometimes sacrifice for the benefit of others.

Parker really means that we become more selfish, that the “others” narrows from our whole society to that small group, presumably our nuclear family, for whom we work and sacrifice. Of course, she is only talking about some people. Some people never have children. Others of us realize that there are benefits that we all want as a society – transportation and police and schools and even a social safety net – that makes us more than willing to pay our taxes. And a few people, very wealthy, accumulate much more money than they or their children could ever use and pay very little in taxes. They, to be sure, are big fans of the popular narrative endorsed by Parker: that the rest of us need to buckle down and take care of our kids and not make a fuss and be socialist and threaten their gravy train. And for sure keep paying taxes, so that when they need to be bailed out the government has the funds.

It is a deeply flawed narrative, but it holds a lot of sway, and is used to justify policies that have facilitated the greatest transfer of wealth, from most of us to a few of them, in a century. More and more Americans are on a treadmill, working harder and harder to discharge their responsibilities to their families and pay their taxes, because their real wages are stagnant or decreasing. Our economy increasingly is one where little is manufactured but we all tithe to the kitty (or is it a lion?) of the financial services sector; its “players” compete for that money taken from the rest of us (anyone seen “The Big Short”?) and it bothers them not one bit. That it bothers a lot of young people enough to support Senator Sanders (who Parker says “never outgrew his own socialist-rebellious tendencies”) should make all of us happy and optimistic, since what is happening now is not good for most individuals, their families, America, or the world.

It’s also not good for a lot of people’s health. The New York Times’ Sabrina Tavernise reports on February 12, 2016 that the “Disparity in Life Spans of the Rich and the Poor Is Growing”. “Experts have long known that rich people generally live longer than poor people,” she begins, but how much longer is increasing. This was most recently demonstrated by a study conducted for the Brookings Institute by Barry Bosworth, Gary Burtless, and Kan Zhang (“What growing life expectancy gaps mean for the promise of Social Security”). Men in the bottom 10% of income born in 1920 lived 6 years less than those in the top 10%; for those born in 1950 it will be 14 years. For women the increase is as great, from 4.7 to 13 years, and for women in the bottom 30%, life expectancy has actually decreased. This is not a good trend, and it is not limited to the outliers in the top and bottom deciles. As illustrated by the accompanying graph, the more you make the longer you can expect to live. Tavernise makes clear that this is despite the advances that have occurred in medicine and technology; indeed those have relatively little impact upon longevity or health, despite the amount that we as a society spend upon them; most estimates of the contribution of all medical care to health status are in the 10-15% range. This is, nonetheless, where most of our health expenditures (now over 17% of GDP) are, and of course to the extent that they are of benefit to individuals they are far more available to those who have more money. Per Tavernise: “The Social Security Administration found, for example, that life expectancy for the wealthiest American men at age 60 was just below the rates in Iceland and Japan, two countries where people live the longest. Americans in the bottom quarter of the wage scale, however, ranked much further down — one notch above Poland and the Czech Republic.”

The Times article quotes the usual sources to tell us that lower income people are likely to have more negative health behaviors, like smoking and prescription opioid use (but, somewhat surprisingly, not that much more obesity – 37% in the lowest and 31% in the highest income group). Health behaviors are important; they may be as significant as medical care in determining our health. So is biology, our individual genetics. But even smoking only accounted for a fifth to a third of the difference.

The real causes of the difference in life expectancy are the “social determinants of health” (SDH). These include having a place to live, having enough to eat, having warmth in the winter, living in a neighborhood with lower rates of both interpersonal (muggings, homicide) and institutional (environmental pollution, lack of access to basic resources like stores, transportation, sidewalks) violence. They also include the occupational risks accompanying many lower-income jobs that involve physical labor and the toll it takes on the body (and increase the probability of living with chronic pain and using opioids). The SDH are tied to other risk behaviors, such as smoking. And, since socioeconomic status is highly correlated with that of one’s family of origin, people with higher incomes were likely to be born and raised in families with higher incomes, which confers a lifelong health benefit. Of course, this negative impact of SDH would be expected to be greatest in the lowest socioeconomic groups, which it is, but above them surely people have those basic needs met? Why are they living less long than the really rich?

A big part of the reason is misperception by the well-off, which includes most policymakers, politicians, pundits, and even journalists of how much money people make, and thus how many people are well-off. The median household income in 2014 (US Census Bureau report) was about $53,000. Half the households made less, and half more. The bottom 80% of income earners account for about 50% of all income, with the top 20% having the other 50% and the top 5% over 20%.  An individual with an income of $100,000 is in the top decile on that table, and so it is less surprising that folks making less have some deficit in their health and life expectancy.

From the Timesarticle: “At the heart of the disparity, said Elizabeth H. Bradley, a professor of public health at Yale, are economic and social inequities, ‘and those are things that high-tech medicine cannot fix.’”. I have cited Bradley before (To improve health the US must spend more on social services, December 18, 2011), and her point, that in the US we spend far more on medical care than other social services, is still right on. We spend huge amounts on high-tech and variably effective care that benefits a relatively small number of people (and, disproportionately, those with higher income) and much less than other OECD nations on other social services that actually improve health and life expectancy. Oh, but those countries spending that money are those “social democracies” that Bernie Sanders goes on about. You know, socialist. The ones where people are healthier and live longer.

Now, why would we expect, or want, our young people to “grow out” of the idea that this is a good thing?

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Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentivefor states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.

On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.

Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.

Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  

Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.

Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.

I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.

There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

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