Inequality is a life and death matter

The Republican effort to gut the Affordable Care Act poses a health care catastrophe. But blocking a backward move isn’t enough. The overall U.S. death rate is rising. The survival gap between rich and poor is widening. Blacks and Native Americans continue to die at appallingly young ages. And the Affordable Care Act, despite offering a modest advance, is deeply flawed.

This disturbing picture emerges from an unprecedented series of articles on inequality and health in the U.S. that appears in the current issue of The Lancet, one of the world’s oldest and most respected medical journals.

The articles document the health consequences of our deepening economic and racial divides. Since 2008, the richest one percent of Americans have captured nearly all of the gains in income and all of the increase in wealth; the average American household has seen its income drop by $1,400 since 1999.

This economic polarization is mirrored by health inequities. Today, the wealthiest one percent of Americans live 10 to 15 years longer than the poorest one percent, a mortality gap that is increasing. While the super-rich are pulling away from the middle class, the health gulf between the middle class, and the working poor and the destitute is growing even faster. We’re witnessing a slow-moving public health disaster.

Meanwhile, structural racism impairs the health of Black and Native Americans. The legacy of past injustice lives on in the form of mass incarceration that damages the health of prisoners as well as their families, and in segregated communities with poor housing, few job opportunities, underfunded schools, polluted air, and a lack of health-supporting amenities like parks, supermarkets and medical care.

Good health care could help close the health gaps; preventable disasters like heart attacks, strokes, suicides, overdoses and infant mortality account for many of the excess deaths. But instead of ameliorating income- and race-based health inequalities, our market-oriented health care system often exacerbates them.

Nearly 30 million people remain uninsured. For them, care is often out of reach nearly one-third of uninsured diabetics don’t have a regular doctor. Millions of people with conditions like high blood pressure and cholesterol can’t afford the medications they need to prevent deadly complications.

And millions with coverage can’t afford to use it. The average deductible in job-based coverage rose 153 percent over the past decade, to $1,478 in 2016. That’s a big financial hurdle for many families. Unpaid medical bills are now the most frequent dings on credit scores and a common cause of bankruptcy. Skimpy coverage also has medical consequences: skipped medicines and increased hospitalizations for kids with asthma, and, for adults with heart attacks, dangerous delays in seeking emergency care, and passing up medications that prevent a recurrence.

The ACA made progress on coverage. Medicaid, which accounted for much of the coverage expansion, is much better than being uninsured. But Medicaid enrollees often have trouble getting appointments with specialists, and some states (e.g. Indiana under then-Gov. Mike Pence ) have imposed daunting premiums and copayments on impoverished enrollees. And much of the ACA’s new private coverage comes with unaffordable deductibles, which averaged $3,064 in the mid-level Silver plans offered on the ACA exchanges in 2016. Meanwhile, out-of-pocket costs and premiums continue to rise apace for the 90 percent of Americans unaffected by the law.

Obamacare didn’t cause these problems, but it failed to fix them, a defect that voters noticed and candidate Trump capitalized on. The ACA merely patched up our dysfunctional market-based insurance system because Democrats deemed more thoroughgoing reform unattainable. But markets don’t work in health care. They distribute care based on purchasing power, not medical needs: the poor, who are generally the sickest, get too little, while the wealthy get unnecessary and even harmful (but profitable) interventions.

The transaction costs of medical markets are also harmful. We’ll spend $323 billion on health insurance overhead this year. Cutting out private insurers and replacing them with Medicare for everyone would save two-thirds of that.

And our Rube Goldberg payment system forces hospitals to devote one-quarter of their total revenues to billing and administration. That’s twice what hospitals spend on administration in Canada and Scotland where they’re paid lump-sum budgets (like our fire departments) rather than billing for each Band-Aid and aspirin tablet.

Moving to a non-market, Medicare for All system could save more than $500 billion annually in bureaucratic costs, and billions more by pushing down drug prices – savings that could improve coverage and care for most Americans, including the 90 percent who didn’t gain from the ACA.

Oddly, Republicans inadvertently triggered new enthusiasm for the single payer, Medicare for All approach they most abhor. It’s not all we need to tackle health inequalities, but it would be a great start.