Inequality in Healthcare Essay examples
Access to healthcare in the us: article analysis.
For many decades the access to health care system in America has been an integral social issue. Of all the western countries US is the only country without a universal healthcare access. The health care system charges a fee to provide access to health and the majority of the population is unable to pay such high fees which keep them out of the health care system. The healthcare system is based on the principles of social inequalities which are based on the socioeconomic status, race and gender. The research paper has discussed the issues and analyzed them by shedding light on the alternatives to improve the healthcare system in the US.
Affordable Care Act
The goal of this essay is to discuss the health care system in the United States. Another aim of this essay is to discuss the health policy, to improve, and to reduce inequalities. In the United States the private insurance system is a major provider of health care services, health care system is expensive and in many cases not efficient. This essay focuses on the patient Protection and Affordable Care Act, Formulating, Legislative, and Implementation stages.
Health Care Inequality Essay
Widening economic inequality in the United States is being accompanied by increasing health care disparity. While the health care system seeks to provide health care as a human right, it fails to do so often worsening the disparities (Dickman, Himmelstein, & Woolhandler, 2017). While health care today has made major strides, there are many people who are still suffering from health care system injustices. Of the people who are still uninsured a majority of them are in the middle-working class or those living in poverty. Poor Americans have less access to health care than wealthy Americans. The life expectancy gap between the rich and poor continues to widen. Health care in poor communities is too often neglected. This issue has been a trend in the United States for many years. In Abraham’s book, Mama might be better off dead these very same inequalities are evident for the Banes family. Because of these inequalities, preventive illness becomes life threatening causing care to then become extensive and even more expensive.
Health Care Utilization Paper
In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.
Essay On Health Disparities
Oh Lord, help all of the black communities to fight back against poverty and give them strengths the disparities around of their communities. Martin Luther King offered his life and died for the cause of inequality, hoping that one day there would not be any discrimination, disparity, poverty and the segregation among the people of color. Nevertheless, people who lived in the black community receive less attention than the elites.
Health Policy And Process Hlsc 3631u
In the 21st century with many developing countries around the world providing universal healthcare, but efforts in the United States are unsuccessful in implementing health reforms. In the documentary (Frontline) examines the worsening economy and broken healthcare system around the United States. With millions of Americans losing jobs, unemployed, uninsured and leading to bankruptcy, which has taken a toll on peoples lives and the healthcare system. This paper will examine and discuss the care identified in Sick Around America and some of the dilemmas they face in keeping it. As well discussing the major differences between the USA and the Canadian healthcare systems.
Disparities In Health Care Essay
I have experienced less than most due to the fact that I am employed by a Catholic, ministry-based organization, and all patients are treated equally regardless of ability to pay. However, if a patient has a connection to the hospital, especially financially, they do no wait in the ER, but are direct admitted by the physicians, to the best rooms available, and receive more frequent visits from physicians. These disprepancies are based on influence and financial contribution.
In “Prevention is Primary” (2010), health disparities are described as “conditions that are avoidable, unjust and unfair” (p. 36). The situation in Florida, with pain clinics on every corner of Broward County handing out prescriptions and/or dispensing copious amounts of extremely potent pain medications, is certainly avoidable. Today our national pain medication abuse has reached epidemic proportions forcing our president to declare a national emergency. As highlighted in the film, the OxyContin Express, anyone is susceptible to the lure of abusing prescription drugs. Todd, a younger, white male, had been abusing oxycontin for years despite the loss of both his brother and wife. The availability and sheer number of pills with little restrictions or regulations in place has brought unfavorable conditions to Florida that promote abuse (Foster, Tanner, & Van Zeller, 2009). The fact that anyone can walk into a clinic and purchase an MRI, have strong medications to regulate “pain” prescribed, and walk out with copious, deadly amounts of drugs speaks to the fact that anyone can and is impacted by health inequalities.
The American Healthcare System Is the Healthcare System Broken?
The paper is broken up in to three sections. In section one, we will discuss the problems with the American Healthcare system and we will try and clear up some of the often misrepresented facts about the healthcare problems and solutions to fix them. In section two, we will present some of the solutions being put forward to fix the healthcare system, including plans by both Presidential Candidates
Comparing The United States Health Care System With The Federal Republic Of Germany
During the past few decades in the United States, health care cost has been skyrocketing, and many people have lost their insurance as result of the high cost. Approximately 45 million American s are uninsured or they don’t have a real health care plan that can cover all their needs. Some Americans have the perception that even with coverage, cost and other problems in the system, the quality of the Healthcare System in the US is better than other countries in the world, something that it is not true. As a matter of fact the United States is one of the richest, industrialized countries in the world where it spends a lot of money in its healthcare system. Spending more money in the Healthcare system does not mean it will be a better system, nor it does not mean it could not improve in some areas. In contrast, the Federal Republic of Germany where its healthcare system is completely different from the United States.
Inequalities in Health Essay
Ill health provides jobs for doctor’s nurses and specialists (P.Trowler, Investigsting Health welfare and Poverty, 1996 p.27) .
Why We Need Universal Healthcare Essay
Many view France’s healthcare system as ideal. This opinion was validated when the World Health Organization ranked it number one in overall healthcare (WHO 2000). Their structure is a multi-payer system which has both public and private sections. It is more
Essay on Inequalities in Health
classes are perhaps not as clear as they used to be. But it is just as
Social Inequalities in Health Care Essay
The Behavioural or Cultural Explanation: places emphasis on the individuals and the consequences of their behaviour, when they choose to eat, drink and live healthily the inequalities will be reduced.
Module 5 Critical Thinking : The Bamako Initiative
In addition to being the largest nation in Africa, Nigeria is one of the most populous nations in sub-Saharan Africa with 178 million people (World Bank n.d). With approximately 50% (World Bank, n.d.) of the population living outside the urban cities, Nigerians experience barriers to accessing health care in the remote rural areas. Furthermore, the high percentage of Nigerians living in poverty, 70% (NationMaster, 2015), provides for financial problems
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Essay On Health Care Inequalities
Examples of health care disparities.
According to Baldwin (2003) health care disparities are the differences in health and health care between population groups including race, socioeconomic status, age, location, gender, disability, and sexual orientation. Disparities limits the improvements of quality health care which could result in unnecessary health care expenses. Factors that are contributing to disparities within today’s society are lack of access to quality health care and the number of individuals who are uninsured. As the population continue to grow and become more diverse health care disparities will continue to increase. Patient centered care efforts will improve health care and will assist with eliminating disparities. Patient centered care will promote patient
Causes Of Health Disparities
Those who work in the health care field can create and promote a plan for decreasing disparities in health care. Interventions can also be held based upon one 's race, social status, age, or any of the other factor contributing to health disparities. Providing health care equally to all people will also assist in ending disparities. If everyone is given equal opportunities and treatment, then everyone will be at a fair advantage for good health despite their race, geographic location, age, or socioeconomic structure.
Disparities In Health Care Essay
For both the uninsured group and those who are eligible for government assistance because of their low economic position, access to health is limited by the number of private providers willing to treat them. In many cases private providers are linked to particular private health insurance companies and won 't accept patients outside their network. These people must then rely on the overburdened public health system for care, and as such usually only seek treatment in emergencies. The public health system, while filled with competent staff, is nevertheless restricted by its funding and can therefore not always provide all these patients with the best quality of care. The inequality in health care access is a continuing issue in America and as such it is important for future consumers and workers on the Foothill College campus to have a thorough understanding of the issue so they can move to improve the problem in the
Health Disparities Essay
The lack of financial resources can be a big problem to access to health care. The lack of available finance is a barrier to health care for many Americans but access to health care is reduced most among minority populations. The irregular source of care is another reason why access to health is a disparity. Compared to white individuals ethnic or racial minorities are less likely to be able to visit the same doctor on a regular basis and tend to rely more on clinics and emergency rooms (News Medical Life Sciences).
Health Inequalities
Health inequalities are a result of unequal exposure to risk factors associated with socio-economic inequalities, such as social, economic and environmental conditions (Thomson, Bambra, McNamara, Huijts, & Todd, 2016).
Racism In The Medical Field Essay
Racism has existed in the medical field for over 2,500 years. Where people of certain races, religions, and genders are all discriminated against by the people in this world who are supposed to help them. Doctors take an oath to treat all patients with equity, yet still some patients are prone to bigoted racism. However it goes the other way as well, even doctors experience racial prejudice by patients and their families. Racism is still immensely prevalent in today’s medical field. No matter which way society spins it, people are racist, sexist, and homophobic to everyone who does not look or act exactly like them.
Essay On Health Care Disparity
Kaiser Family Foundation (2012), health and health care despairs refer to differences in the health and health care between population groups. The health disparity generally refers to a higher burden of illness, injury, disability, or mortality experienced by one population group relative to another. A health care disparity typically refers to the differences between groups in health coverage, access to care, and quality of care. While disparities are commonly viewed through the lens of race and ethnicity, they occur across many dimensions, including socioeconomic status, age, location, gender, disability status, and sexual orientation (HKFF,
Social Determinants Of Health (SDOH)
Health outcomes among people depend upon the resources that people have to live a quality life. The variations with the money distribution and power derive such circumstances and induce inequalities in health at domestic and global levels where they have become unavoidable at present (Vega & Frenz, 2013). It has been stated that income, housing as well as environment are the major categories undermining all the factors of social determinants as mentioned earlier. Individuals, groups and communities are negatively influenced by these factors in their health status. Governments of all nations have undertaken several measures to tackle the risks arising from these conditions (Chapman, 2010). These disparities that exist in all the factors have to be eliminated with suitable control measures. Regulations on health care services and their access has to be made more
Health Inequalities Essay
Health inequalities are preventable and unjust differences in health status experienced by certain population groups. People in lower socio-economic groups are more likely to experience chronic ill-health and die earlier than those who are more advantaged. Health inequalities are not only apparent between people of different socio-economic groups – they exist between different genders and different ethnic groups (“Health inequalities,” n.d.).
Health Disparity In Canada
Health disparity are avertible health status of distinctive group of people like races, skin color, language, socioeconomic resources, gender and age (Edelman, Kudzma, & Mandle, 2014). Health disparities are arbitrary and explicit to historical and present uneven distribution of political, economic, social, and environmental resources. A disparity can also be related to education, where dropping out of school occurs associated with various social and health problems (CDC,2017). Comprehensively, person with inadequate education are more likely to struggle number of health risks such as substance abuse, obesity, and traumatic injuries, compared to individual who receive more education. One of the main findings within health disparities in history
Health Care Disparities Research Paper
Health care disparities are unfortunate and being culturally competent is an essential step toward eliminating these inequalities. In this discussion, I will review what disparities are associated with the Appalachian culture and how they affect health status, employment, and education. I will also identify two nursing interventions that could be taken to help decrease the affect that health disparities have on the Appalachians and review what the biggest challenge would be when implementing the interventions.
Universal Health Care Essay
As Bernie Sanders once said, “Health care must be recognized as a right, not a privilege.” Most developed countries choose to live by this quote while the United States of America chooses to go against it. Universal health care has benefits on multiple levels, whether it’s a single individual or the people in a whole. The U.S is one of the few developed countries that doesn’t offer universal health care to their people, yet the U.S spends more than seventeen percent of their GDP on health insurance. Many people believe that universal health care is a simple one solution problem, but the truth is that there are multiple forms of universal health care that provide all citizens with the health insurance they need.
Essay On Health Care Cost
Health care cost has seen to increase gradually as years go by. This has been influenced by major factors such as political influence, emerging chronic diseases, new procedures that are coming up including the technologies being invented for treating illnesses, pricing of medicines and treatment is not regulated and when treating ailment their may arise repetition of tests or a patient gets over treated for a particular ailment.
Health Care Should Be Free For Everyone Essay
Have you ever seen the dirty, homeless people on the streets? Maybe if they had access to health care, they could clean up and look better. Nevertheless, if that homeless person could clean themselves up, they could interview for a job and start a new life. Major reasons for this is, it would save lives, in the long run it’s cost-effective, and providing free health care helps people gain access to insurance. Basic health care should be free to everyone because, it could save lives, in the long run it’s cost-effective, and providing free health care health people gain access to insurance.
Health And The Social Definition Of Health
In my essay, I will first define the meaning of ‘health’ from different perspectives. Then, I will talk about how social factors such as gender roles and economic positions determine a person’s health. At the end, I will suggest methods to solve the health inequality.
More about Essay On Health Care Inequalities
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Home > DISSERTATIONS > AAI3594849
Three essays on health inequalities
Ameed Saabneh , University of Pennsylvania
Health inequalities exist in many societies and mostly reflect inequalities between social and ethnic/racial groups. This dissertation consists of three independent studies of health inequalities. Each study examines a different source of inequality and focuses on a particular health outcome. The first study investigates inequalities in old-age morbidity between Palestinians and Jews in Israel. It examines the role of social inequalities between the two groups in creating gaps in their health statuses. The second study investigates the effect of maternal employment on child survival in India. In particular, it examines reasons for the higher mortality among children of working mothers compared to children of nonworking mothers. The third study focuses on differences in child survival and nutritional status between Copts and Muslims in Egypt and examines the contribution of socioeconomic and regional differences to Copts' higher child mortality during the 1980s and early 1990s. All three studies use propensity score matching. Results from the first study show that morbidity gaps between Palestinians and Jews in Israel are only partially explained by social inequalities. In addition, it shows that the relevance of social inequality within the majority group to understanding minority-majority health gaps. Results from the second study indicate that children of low-status female workers face a higher risk of dying relative to children of nonworking mothers, which most likely results because of extra pressure put on poor working mothers who have to fulfill the role of income earners and care givers in addition to fulfilling time-consuming domestic work. Results from the third study indicate a higher mortality among Copts in spite of their moderate socioeconomic advantage and higher concentration in urban areas. The Copt-Muslim child mortality gap results partly due to higher concentration of Copts in Upper Egypt, a region characterized by high mortality rates relative to the other regions of Egypt.
Subject Area
Middle Eastern Studies|Ethnic studies|Health care management|Demography
Recommended Citation
Saabneh, Ameed, "Three essays on health inequalities" (2013). Dissertations available from ProQuest . AAI3594849. https://repository.upenn.edu/dissertations/AAI3594849
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Essay On Health Care Inequality
Health care inequality has long been customary in the United States. Those in lower classes have higher morbidity, higher mortality, higher infant mortality, and higher disability. Millions of low-income families and individuals have gone with out the care they need simply because they cannot afford it. Denial of benefits due to pre-existing conditions, outrageous deductibles, and unreasonable prescription prices are in large part why the low-income class suffers. In addition, not receiving preventative health care, lack of access to exercise equipment and lack of availability to fresh foods all create health problems that become to expensive to fix. Low-income families need to have better, more affordable access to health care, specifically preventative health care, and be more educated about the benefits of health care in order to narrow the gap of inequality. The new Affordable Care Act under the Obama administration expands heath care coverage to many low income families and individuals by lowering the eligibility requirements for Medicaid , although it is not mandatory for individual states to make this expansion for Medicaid coverage.(CITE) It also requires that preventative health care be included in coverage by insurance companies. So with all the benefits the expansion of Medicaid could offer, why would some states choose not to offer it? Under the Affordable Care Act one of the most important provisions is to expand health care to low income families through Medicaid. This could have an effect on over eight million people who do not have access to health care currently. However 25 states have decided against expanding Medicaid benefits, leaving 13.5 million people less likely to receive basic health care and preventative ... ... middle of paper ... ...Medicaid covers. The allergy shots will not only help my severe year round allergies, they will help to control my asthma . While there are some valid concerns with expanding Medicaid coverage, I think the benefits far out way the risks. Pregnant women will be able to receive the prenatal they need to deliver a healthy baby, reducing infant mortality rates. Millions of Americans can receive preventative care that can catch things like cancer in early stages. High blood pressure and diabetes can be better regulated in low-income individuals leading to fewer deaths caused by these diseases. Furthermore, millions of Americans will be able to afford the prescription medications they need. Every state that is opting out of the Medicaid expansion has a republican governor that is against the program. Maybe these states should care more about their residents than politics.
In this essay, the author
- Explains that health care inequality has long been customary in the united states. denial of benefits due to pre-existing conditions, outrageous deductibles, and unreasonable prescription prices are in large part why low-income families suffer.
- Explains that under the affordable care act, one of the most important provisions is to expand health care to low-income families through medicaid. 25 states have decided against expanding medicaid benefits.
- Explains that infant mortality is associated with poor prenatal care, poor maternal health, and poor quality and access to health care and preventative services.
- Explains that the expansion of medicaid would provide coverage to nearly half of the united states uninsured people.
- Explains that states don't want to expand medicaid coverage because it will put restraints on the state's already tight budget.
- Explains that they have lived with chronic asthma and allergies since they were two years old. they were kicked off their health insurance when they turned 25.
- Describes the colorado indigent care program (cicp) that offered health care discounts to students and single mothers. the program was designed for low-income families and individuals that were not eligible for medicaid.
- Explains that some states are deciding against expanding medicaid coverage due to the fear that the existing medicaid participants will have an even harder time getting appointments.
- Opines that while there are valid concerns with expanding medicaid coverage, they think the benefits far outweigh the risks.
- explanatory
- argumentative
- Explains that under the new health care reform law, most people will receive help paying for their healthcare premiums and cost-sharing expenses that people with insurance have to pay out of pocket for doctor visits, and prescription medicine.
- Explains that public option is an alternative solution to affordable healthcare for all. it works by having a government-run healthcare program which is exclusively available to two groups that lack employer-provided health insurance.
- Explains that public option is taking on full effect by the end of 2013 and it will be a self-sustaining program that is able to run without government subsidies.
- Explains that single-payer health care is a form of healthcare programs that cost absolutely no money at all.
- Argues that single-payer system makes sense for middle to low-income families since paying for health insurance separately can put a huge dent on their wallets.
- Explains that obamacare's medicaid expansion is specifically designed for poor working families that are most likely to not have insurance due to financial obstacles.
- Opines that obamacare's medicaid expansion is a great way to help families below the federal poverty line get insurance and stay healthy. without it, they will fall between the cracks forcing them to use obamacare.
- Opines that the medicaid program can be rescued and revitalized by leadership; otherwise, it is likely to erode.
- Opines that reform is needed for the health care system in order for americans to live a life that is both safe and prosperous.
- Opines that the united states is the only developed country that does not provide comprehensive health care to all its citizens.
- Opines that the american people want health care for all, not just medical needs, but the ability to pay.
- Argues that the nation's piecemeal approach to insurance doesn't keep americans healthy, and costs more in the long run. we must embrace a world-class health care system affirming the worth and dignity of every human life.
- Opines that the outlook of healthcare under president bush's administration is likely to get worse if senator john kerry had won the election.
- Explains that medicare is going broke and the government has to pump money in it to keep it going which in turn adds to the debt.
- Argues that the federal government should focus on getting generic drugs onto the market and relinquish more control of medicare to the states to help lessen the national deficit.
- Analyzes the flaws in marilyn moon's article about the mythology surrounding the medicare reform.
- Opines that if the economy grows enough, we can double or quadruple what we spend on health care for the elderly and everyone else in the society will still have more real income left over.
- Analyzes the effects of medical research on health care and the economy in the 21st century.
- Explains that the uninsured are a growing concern in the world today, and that healthcare costs are increasing in many countries.
- Analyzes robert scuka's article titled "health care reform in the 1990s: an analysis of the problems and three proposals."
- Argues that the current medicaid policy should be streamlined to benefit the states. federal restrictions on eligibility hamper the state's ability to provide services to indigent residents.
- Cites jonathan oberlander's article medicare: issues in the political economy in the journal of health politics.
- Analyzes the effects of medical research on health care and the economy, by herbert pardes, kenneth g. manton, eric s. lander, h. dennis tolley, arthur d. ullian, hans palmer.
- Explains that the aca is favorable for national economic growth and, consequently, opens up jobs for many citizens.
- Argues that the cost of realizing the aca will be too high for the federal budget, and that business owners are constantly looking for ways not to cover insurance for their workers.
- Argues that the affordable care act is an important stage in the american healthcare development process as it allows more people to receive healthcare services and reduces the deficit.
- Argues that the aca is the most suitable solution as other plans pose a threat to the middle and poor classes of the country.
- Reports that 49% of the country's population has group health insurance coverage provided by an employer, whereas 57% of companies offer it to their employees.
- Describes the books that were published by oxford university press, including dunn, edwards, and lepore, jill.
- Opines that the affordable care act is important because it reduces the disparities of minorities in medicine.
- Explains that for many of the poor in america, health insurance is something that is not feasible. the financial aspect of minorities and healthcare isn't the only problem.
- Explains that higher mortality rates in minorities are the result of their inability to receive affordable healthcare. lack of insurance is one of the main reasons why there is disparity between minority and whites when it comes to receiving health care.
- Explains that economic disparity is a major problem, not only for affording insurance, but also for general health.
- Argues that universal health care is beneficial for the 6% of americans that need it, but many insurers don't provide coverage to those who have a preexisting condition.
- Explains that education is an important social factor in determining the overall health of an individual. the affordable health care act solves this problem by making it so that everyone can afford coverage and still have money to support them financially.
- Analyzes how universal access to health care reduces health inequalities in countries like canada, where equity in the availability of health services has been improved through universal healthcare.
- Argues that health insurance premiums will go up under the new health care law, but insurance is already rising due to obesity and smoking among americans.
- Explains that access to health care is heavily influenced by socioeconomic status, as wealthier population groups have a higher probability of obtaining care when they need it. the affordable care act addresses this by providing everyone who is uninsured with the ability to receive insurance.
- Explains that the government program's funding is from tax payer money, and some would rather have everyone pay for their own private insurance. uninsured individuals cause hospitals to charge more to elevate the cost of care.
- Argues that social inequality and economic inequality has become an ever-increasing problem in america.
- Explains that race is a significant determinant in the level of quality of care. hispanic children are almost three times less likely to receive routine health care than white children.
- Opines that the affordable care act can help many who cannot afford medical insurance, especially minorities who struggle to purchase health insurance.
- Explains that healthcare is a complicated thing, but there are lots of things that need to be addressed.
- Explains that in the case of u.s. health care, only those who are "privileged" enough to afford it can receive it.
- Explains that medical care in the united states is a $2.5 trillion industry — the u.s. health care system is the world's eighth largest economy, second to france, and larger than the total economy of italy.
- Opines that healthcare is important for people even young women having babies, as it allows them to not have so much stress about the safety and access they can get at a medical center.
- Analyzes how the term "responsibility" in the united states is vague, since healthcare is a right to everyone, and people who are poor should not receive access to healthcare.
- Explains that the affordable healthcare act has changed the face and culture of united states healthcare. it sparks intense feelings and emotions both positively and negatively across the board.
- Opines that changes that could improve the affordable healthcare act are to settle the restorative negligence framework, deny and throw out the singular state, settle on a more serious decision necessities for individuals with medicaid, and offer protection trade subsidies.
- Argues that the healthful misconduct structure is the reason behind high using and unnecessary therapeutic administrations.
- Opines that the affordable healthcare act won't work well if individuals hold off on purchasing protection until they get sick. republicans and voters see it as an unnecessary government attack in individuals' lives.
- Explains that the majority of patients don't understand why they're getting the surgery or how they can hope to profit from it. the specialists need to update their patients about any choices that could better them.
- Explains that kathy sabadosa, 43, of norwich vermont, was diagnosed with breast cancer two years ago.
- Argues that the supreme court struck down the prerequisite that states stretch medicaid capability to all adult individuals under 133 percent of the poverty line.
- Concludes that the affordable healthcare act should be beneficial to low-income americans and congress should debating on more proposals to improve it, rather than pursuing a path that neither defunds it nor fixes its shortcomings.
- Explains that the affordable care act provides low-cost, government-subsidized insurance options through the state health insurance marketplace.
- Explains that obamacare's changes in requiring all americans to have affordable coverage will allow those with medical conditions and disabilities, as well as women who need pregnancy care, to be insured without having to potentially be denied coverage or forced to pay a much higher than average price.
- Explains that obamacare requires maternity care to be a part of all new insurance plans. the practice of "gender rating", which allowed insurers to charge women higher premiums, is no longer allowed.
- Explains that obamacare brings affordable healthcare coverage to over 32 million americans who are currently uninsured. the affordable care act expands medicaid and the children’s health insurance program, as well as improving the quality of medicare.
- Explains that obamacare addresses the 'donut hole' in medicare, which is planned to be closed by 2020 under the current affordable care act.
- Explains that 54% of americans are opposed to the affordable care act, despite it being approved four years ago. the opposition has given a number of supporting key points for their position.
- Explains that the addition of more major governmental programs such as healthcare subsidies has many worried that it will only plunge the united states further into debt.
- Explains that pharmaceutical companies will be paying for obamacare to close the coverage gap in medicare.
- Explains the disadvantages of reduced coverage options from employers and the penalization of those who are already on private healthcare plans.
- Opines that the opposition to obamacare raises some good points, especially in our current economic climate, but the supporters are also correct in saying the current system is not sustainable in the long-term.
- Analyzes the pros and cons of the affordable care act, including reduced discrimination by insurance companies, increased regulation of their practices, and affordable healthcare for the large quantities of uninsured americans.
- Cites kimberly amadeo's article, "obamacare pros and cons." about.com, 14 dec 2013.
- Explains that mental illness affects americans and disproportionately impacts the poor. the us government's outreach is unclear and millions will lose out on health insurance due to poor information.
- Explains that mental health in the usa needs a new system, despite expansion in half of the states.
- Argues that expanding medicaid is not the best option for individuals with mental illness, but it is the only opportunity that increases availability of healthcare for those in need.
- Argues that the government should be able to make incremental reforms such as the expansion of medicaid state by state and on another prong, campaign to illuminate mental illness as a real disease.
- Opines that it is practical to project the future of healthcare, as the pharmaceutical drug, and insurance companies run the system.
- Opines that the expansion of medicaid should be celebrated once completed, but we should not be content with the current fragmented system of mental health.
- Argues that mental health should be a priority to combat the cyclical nature of poverty, drug addiction, and mental illness. medicaid expansion is bleeding out in states dominated by partisan politics.
- Cites the kaiser commission on medicaid and the uninsured.
- Explains that medicare and medicaid are two of the united states largest broken systems, which must sustain themselves in order to provide care to their beneficiaries.
- Explains that medicare is designed for beneficiaries sixty-five years and older and enrollees who are permanently disabled and are unable to work. medicaid is health care benefits for low-income and do not have insurance through their job.
- Explains that medicaid supports children under the age of nineteen, people over sixty-five, enrollees who are disabled, and those that need permanent nursing home care.
- Explains that medicaid is sometimes used to help pay for medicare premiums and those who do quality for both programs are considered "dual eligible" and enroll in both to cut personal costs. federal and local governments have a responsibility to provide funding to support these programs.
- Explains that medicare managed care plans provide basic medicare coverage, the size of premiums and copayments, and the decisions about paying for treatment.
- Explains that medicaid provides a comprehensive benefit package for those who enroll, including inpatient and outpatient hospital services, nursing home and home health care, and for children under the age of 21.
- Explains that medicaid is one of the several components that make up the nation’s health care system.
- Explains that medicaid policymakers struggled with adequate financing and coverage, and many health care providers were reluctant to participate in the program. medicaid faced growth and serious spending before managed care could be seen as beneficial.
- Analyzes how medicaid has grown in terms of who it covers and what it costs. children and non-disabled adults account for the majority of medicaid enrollees, but only seventy-two percent of eligible children enroll for medicaid services.
- Explains that medicaid's elderly and the disabled primarily use long-term care services, while spending for acute care is set aside for adults and children. nursing home facilities and home health care organization spending is on behalf of the elderly enrollees.
- Explains that medicaid is only one category of state government spending and that it competes with other programs for scarce budgetary resources.
- Explains that medicaid is built upon to cover new populations, to support clinical health care providers, and to compensate for the limitations of public and private health insurance companies.
- Explains that medicaid imposes a substantial fiscal burden on states and provides fiscal relief. the burden comes from the growing cost of health care and the expansion of the program.
- Analyzes how medicaid's budget woes are secondary to its insignificant structure, leaving its beneficiaries with limited choices when arranging for their own health care.
- Explains that medicaid is a need-based program that is funded by the federal government and the state government.
- Explains that medicaid was formed as a medical care of federally funded programs providing assistance for the poor, with an emphasis on supported children and their mothers, the disabled, and the elderly.
- Explains the pros and cons of medicaid because it deals with the federal and state government.
- Explains that medicaid kept state control and was coherent with the constitutional framework of the federalism government, despite numerous tough federal orders.
- Concludes that medicaid involves federalism extensively and can come with many pros and cons as well as benefits and drawbacks. states are trying to find new ways to implement this policy.
- Analyzes the effects of state medicaid policies on the dynamic savings patterns and medicaid enrollment of the elderly.
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Causes and Impact of Health Inequalities
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Understanding Health Inequalities Essay
Introduction.
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Understanding what is meant by health inequalities is the first step in addressing the issue. Two central and separate UK health inquiries; one from Acheson and the other from the black report, helped to develop extensive debate regarding health inequalities. Subsequently, they triggered the need for policy and action in addressing the issue.
Different conceptual models have been used to explain and demonstrate how various factors influence individual and community health. Some of these factors such as age and sex are beyond d human intervention.
On the other hand, there are other wider factors which affect an individual’s health, and which can be controlled. There are various numerous debates related to the causes of these inequalities as well as on the most plausible action that should be taken to address these inequalities.
Health equity, also known as healthcare inequality or healthcare disparities refers to the differences that prevail with regard to the quality of health and related activities transversely different populations. The concept of health inequalities was not been a priority for the UK government in the 1980s and early 1990s.
In the 21 st century, evidence for escalated inequalities in the social pattern of health is beyond reasonable doubt and there is vast literature to support this. More than 800 empirical and conceptual papers have dedicated their time and effort to this topic since the late 1990s.
The area of research in health inequalities has been greatly politicized, right from the ideological context through explanatory frameworks to the various discourses that propose remedies to the problem. Reducing inequalities in health has become an integral part in as far as the UK Government policy is concerned.
The key debates related to inequalities and health in the UK, are on the causes on these inequalities and how they can be resolved.
Public health in Britain today is more or less of a paradox where despite the fact that Britain now experiences greater health than it has ever experienced in history, health inequalities had remained to be stubbornly ubiquitous. Several authors have come forth to present the setbacks of health inequalities in the United Kingdom.
This paper aims at identifying and critically reviewing what different authors have got say about this issue in their different works. It has analyzed different conceptual and policy debates which are paramount in as far as inequalities in health are concerned. It has pointed out the respective material and psychosocial influences on health inequalities.
The paper is quizzical on the direction ought to be taken by public health professionals in influencing policies, as well as their implementation in relation to health inequalities. This is of concern in a world where much emphasis is on wealth creation as opposed to addressing poverty.
The years 1980-2005 were a period marked by huge growth in international research and vast literature aimed at demonstrating the inequalities in health, and the governance of poverty as a potential cause of these inequalities. Davey Smith and colleagues at the University of Bristol have made great contributions to this concept by generating evidence to support it.
Davey Smith, et al (1999) responded to Acheson’s report (1998) on health inequalities evident in the UK. The Acheson’s report shows the existence of health disparities and their correlation with social class. The findings showed a general decline in mortality between 1970 and 1990, but that of the upper social classes was characterized by a more rapid decline.
Acheson mentions 39 policies that are applicable in ameliorating health inequalities in various sectors of the economy that range from taxation to agriculture. This report had a great influence on “Out Healthier Nation: A Contract for Health”, the 1998 government green paper and the 1999 “Saving Lives: Our Healthier Nation”, white paper.
Davey Smith, et al not only reviewed Acheson’s data indicating the escalation in health inequalities but also argued that the solution to this escalation could be easily solved.
He states, “Any child can tell you how this can be achieved: the poor have too little money so the solution to ending their poverty is to give them more money. Poverty reduction therefore can be really attained by throwing money at the problem”, (Davey Smith, et al., 1999, 378).
Labonte, 1999 has also placed an argument based on Acheson’s report. Labonte says that there is need to go beyond just analyzing health inequalities to grappling with policy options. Labonte notes that Acheson’s and related reports did not bring about change, instead they became legitimizing tools for those who were committed to change.
They are basically ideological tools which are more essential than evidence base in creation and development of policies. However, Acheson did not provide a basis for continued debate on inequalities within the government.
Acheson has been criticized by Labonte as not relating economic practices with social inequalities as he has done with social aspects and health inequalities. Acheson also failed to probe into the existence of poverty hence has left some crucial components related to health and inequalities unturned.
O’Keefe (2000) has argued out the causes of health inequalities based on globalization, which is considered to have an increasing influence on social policy in all countries.
She explains that decisions related to health inequalities are made by “undemocratic trans-national regulatory organizations that include the World Trade Organization”.
O’Keefe suggests that deliberative democracy placed at the heart of such trans-national bodies could be an ideal solution for the health inequalities experienced in the different countries. However, this was dependant on the world-wide strength to question the unjust social structures that operate on a global level.
In her work, Stewart-Brown 2000 probes into the causes of social inequality. Stewart-Brown is puzzled by the impression derived from this question. It has become more or less like a taboo in literature. Stewart-Brown has used a contrary analytical approach different from that of Davey Smith, et al., and Labonte as discussed earlier on. She has borrowed from conflict management and psychotherapeutic theory.
She implies that the problem of social inequalities in health can be resolved by a development in the direction of emotional literacy involving all income groups and especially those with most wealth by so doing (Stewart-Brown, 2000).
Davey Smith, et al., (2000) have demonstrated that ethnic differences in health status in their review on the UK epidemiological evidence on ethnic health inequalities. Various types of explanations have been explored in this review that entail migration, culture, artefact, behaviour, biology, socioeconomic factors and racism.
They conclude by suggesting that influences falling under the different explanations would largely contribute to the production of ethnic differentials in health. However, production of more sensitive socioeconomic indicators is required if clarity and definitiveness is to be achieved.
Bolam, et al., (2003) have focused on an important and current issue of debate on inequalities in health based on the contribution of psychological factors while looking at structural, material and economic factors related to health.
Bolam and others have advanced this debate by coming up with a more complex and entirely socialized theory that examines the key component in psychological explanations known as the “the sense of control over health”. In their article, Bolam and others explore these determinants by analysing interviews where 30 lower socioeconomic status participants engaged in the interviews.
The participants were obtained from two qualitative studies on health inequalities. The major findings were bent on the correlation of two contrasting factors on control over health, that is, “fatalism and positive thought”.
The debate on material and psychosocial explanations for health inequalities has imperative policy implications and especially macro-economic policy and appropriate interventions with regard to health services. There is one important health service intervention in the UK aimed at reducing health inequalities, and this is the nation-wide programme on smoking cessation.
Woods et al (2003) have noted the implementation of this programme during early implementing health action zones. Woods and others are not at all enthusiastic about this programme because it is only a rhetoric act by the government but, despite this, smoking cessation has been categorically and centrally steered.
They argue that despite the fact that smoking cessation may lead to an overall population-level minimization in smoking, it have the potential of causing a wider gap than the current one in as far as health inequality is concerned.
A similar theoretical debate by Muntaner, et al., (2000) in their thought provoking article have brought focus on the worth of the concept of ‘social capital’ with regard to comprehending and identifying an appropriate action on health inequalities. Muntaner and others have challenged the theoretical value as well as the evidence base that shows social capital to be a determinant of health inequalities.
They show the use of social capital as an alternative to party politics and economic redistribution within the state and it is because of this that they are sceptical about its practical benefit in addressing health inequalities.
Morrow (2000) explores the accounts of young people with regard to the community and neighbourhood while using the concept of social capital, and the effect on health inequalities. In his work, it is evident that Morrow realises the limitations of the social capital concept but Morrow has argued out that it is valuable in helping the young people explicitly understand their social environment.
Ostry, et al., (2000) studied the “relationship between unemployment, technological change and psychological work conditions in restructured work places in British Columbian sawmills”. In this study there was a downsizing of the employees where reduction took place in terms of number and job title.
It was evident that psychosocial conditions of work were ameliorated after the downsizing but, only few workers experienced these better work conditions. Even though this was the case there was a need for future improvements based on the lessons learnt.
To start with, a population based approach is very important while assessing the implication of downsizing because a long-term follow-up of the downsized workers is important. Secondly, there is great need to pay attention to the long-term implications associated with employment and their effects on health with regard to the downsized workers and especially those who are less than 35 years.
Also, the downsizing resulted in escalated levels of control, which was more steepened across the different job categories in 1997 as compared with 1965. This was considered to have health implications and mainly so for the unskilled workers where downsizing had taken place. Lastly, the method used for assessing the working conditions needed improvement. Self-reports ought to be used in such future studies.
Methodological challenges are evident in relation to evaluating the policy interventions aimed at reducing health inequalities. Evans Shito and Keskimaki (2000) have placed great attention on the description of the long term Finnish policy goal addressing health inequalities. They have outlined the barriers to successful policy programmes with regard to addressing these inequalities.
In a similar light of debate, Evans and Killoran (2000) have made a report on “realistic evaluation”. In this report they have realistically evaluated five UK projects put in place so as to test the effect of five partnership models in addressing health inequalities.
They identify six key themes, which are “shared strategic vision, leadership and management; relations and local ownership; accountability; organizational readiness and responsiveness to a changing environment”.
The need to understand how the mechanisms used in the project were executed in the light of local and national policy change has been greatly emphasized. Lessons for programmes on health improvement in the UK, primary care groups and health action zones have been identified.
Asthana and Halliday (2006) have argued about health inequalities with regard to how they should be objectively tackled in the UK. This is in accordance with the prevailing scepticisms on the best approach to take while translating broad policy recommendations into practical actions. The value of local level initiatives has remained to be a great concern due to its implicit nature.
In this book, key targets for intervention have been identified via a comprehensive exploration of the directive and procedures that lead to health inequalities across populations. The authors have examined both national policy content and local practice in determining what is applicable in addressing health inequalities, why and how it works.
This book is authoritative but, very much accessible in providing a detailed account of “theory, policy and practice” hence, creating a good debate ground for what works and what does not work in as far as addressing health inequalities in the UK is concerned.
An article by Buch, 2010 on “Health Inequalities in the UK-Our most Pressing Problem” has presented a debate that was held by the British Medical Association on health inequalities. The debate was centred on the most pressing problem at hand: why there was such a great gap between the different sections of the British population in relation to health and what the most ideal solution to the problem was.
Evidence by Professor Marmot showed that there was a seven year gap with regard to life expectancy. There was also a 19 year gap with regard to healthy life expectancy between the lowest and the highest socioeconomic groups. Ameliorating health inequalities via trying to equalize the socioeconomic status of each and every person would be faced by major challenges. Health agenda was considered to rhyme the environmental agenda where walking, moderate consumption of meat and cycling were encouraged (Buch, 2010).
The question therefore was on how health inequalities could be effectively addressed. Lack of commitment and will are some of the suggested reasons for the persistent escalating health inequalities. There is weighted evidence that the gap related to health inequalities can be filled through policies already developed.
However, the politicians are still struggling with the direction in which they would take in implementing the changes. The government continuously comes up with various ideologies on how to address the health inequalities. Unfortunately, they never get to seriously work on them as they are always debating on how these inequalities could be addressed without doing anything.
“The Impact of Inequality: How to make Sick Societies Healthier” by Wilkinson (2005) is a continuation of his book, “Unhealthy Societies: The Afflictions of Inequality”. The current book reviews the present status of knowledge and offers an explanation as to what causes the health inequalities as well as providing potential solutions to the problem.
This book consists of highly assembled and valuable evidence with an articulate and convincing argument suitable for use by epidemiologists, policy makers, social scientists, public health officials and students.
It is Wilkinson’s ideologies that provoke thought like when he wonders of the difference in government’s response to health inequalities if income gradient in relation to health were to be different. An illustration of this is what the response would be if the higher income groups were the ones experiencing worst health.
Wilkinson has written the book from a particular point of view, that which focuses on social justice and reform. He does not criticize capitalism as per se and does not posit extreme ideologies. Wilkinson’s view of social progress is very much in existence in the contemporary UK society, where market is part and parcel of the existing societal structure.
According to Wilkinson, inequalities in health can be reduced, better stress management mechanism developed to reduce social stress and the quality of social relations made to be better. All these efforts would play a very vital role in improving the health and well-being across populations in the society.
His conclusion is on an optimistic stand-point as he acknowledges the health inequalities across populations but then again, he says that change is very much possible and that the health inequalities can be reduced.
The universe is still in the process of expansion in as far as moral democratic values are concerned, this coupled with growing sensitivity to the suffering of others, Wilkinson points out that a decrease in inequality and improvement of well-being across the social classes was very imperative in strengthening political goals.
Carlisle (2001) has presented the debates related to inequalities and health based on three different explanatory discourses as presented by Macintyre (1997). The first, hereditarianism explanations, on class variations in relation to disease have been presented based on the argument that people’s social position is dependent on natural capacity that is biologically determined.
Based on this perception, variations in health are considered to be inevitable and nothing much can be done about them. Behavioural explanations have been used to justify the high mortality rate amongst labouring classes and ill health of the economically poor sections of the population as a subsequent result of working-class maternal ignorance alongside living conditions that are not up to standard.
In this case, education would have been a preferable measure in improving health. The environmental aspect attributed causes of inequalities in health considered to widespread poverty and material components of urban industrial life. Based on the latter, social reforms were considered to be of great value in addressing the environmental aspect in as far as health and inequalities were concerned.
Popay, et al., (1998) in their review of modern research, have presented a debate based on two main constructions that continue to govern research pertaining to health inequalities. The first construction is individual behaviours and lifestyle while the second one is social inequalities and injustice.
There are some elements of continuity with regard to historical environmental explanations on poverty and deprivation, and behavioural/ hereditarianism explanations on lifestyle and culture the causes of health inequalities.
Nonetheless, differences exist in relation to social values and political ideology in the different explanatory discourses and all are directed at identification of appropriate and applicable policies.
Carlisle concludes by suggesting that lack of clarity revolving around competing explanations fosters political skilful moves at the policy level where the UK government seeks leadership in grappling with the issue, while delegating responsibility to community members and individual figures.
Carlisle presents an overview of three but highly contested explanations that are linked to inequalities in health in the contemporary world. These are poverty/deprivation, psychological stress and individual deficit. The deprivation facet is a strong evidence for the inequalities but it is not complete.
Various critics focus on the barrier of the gradient since health inequalities are not only found within the poorer segments of the society but are a sequel of social class gradients (Marmot et al., 1991). Material differences therefore are not adequate in explaining this. The psychosocial stress model was developed to fill in the gaps from the poverty model.
It views the problem as a generative mechanism for inequalities in health based on the relationship between the individual person and social structure. The individual deficit model has similarly acknowledged social inequality but does not focus much on restructuring the society as compared with addressing the problem and at individual level, examining their culture as well.
Heller, et al., (2002) has argued out the widening and large gap in mortality rate between those at the extreme ends of social distribution despite the amelioration in overall mortality rate. It is this gap between the extremes that has been indicated to be the relative mortality variation between those who experience greatest and least deprivation.
Heller and others have shown that the changes in social distribution that transverse the population has been a major contributor to the reduced mortality rate. Heller and others have argued out that based on their findings, there is no widening gap in overall health inequality when redistribution within the social classes is factored in.
According to the review of both Mackenbach and Kunst (1997) on the different methods of overall health inequality assessment in any population, none of them can be pointed out to be the very best.
Heller and others have used a method that does not directly address the issue despite the fact that it is flexible to changes in social class distribution and allows description of mortality within social classes. Unfortunately, Heller and others have used a method that presumes that every member within a certain social class has the same predisposing risk of mortality.
In addition, when one moves from one social class to another, he or she adopts that mortality profile of that new social class. This is not usually the case and especially in the short-term. The method used to sasses the degree of health inequality in relation to the widening gap of mortality between the extremes of social distribution may be inaccurate as the change may be partly attributed to artefact of health selection.
Inequality is a term that has been used in relation to the distribution of health or ill-health across populations. This ideology or concept is not just an expression of existing differences in relation to race, sex, age and species which exist.
It is neither a mere expression of the natural physiological constitution or procedures involved that have been socially and economically developed. The vast literature and attention on “health inequalities” show that this issue is very much complex. This literature has demonstrated that recognizable and discernable factors related to health inequalities are not easy to isolate from one other as they are very much entangled with one another.
The differences that prevail between people are considered to be eternal and not capable of being modified. The society is made up of various institutions. These institutions can influence health inequalities indirectly and subtly, or directly and evidently.
Some individuals think that this concept of health inequalities is associated with moral reinforcement while others consider it to be non-existent or not yielding into any consequences. The latter consider health inequalities to be inevitable and are as a result of man’s desire to build society. They consider the scope for change to be limited and of miniscule importance.
The concept of social class has been evident in the various literatures. Populations are not alike in terms of literacy, wealth, income and housing. The population is thus divided into strata and societies differ based on these strata. However, it is difficult to identify the borders between the different the different strata but, this does not mean that the strata are less real.
On the contrary, the social strata are sections of the population that share the same types of resources and have similar lifestyles. Controversy continues to prevail with regard to the origin and importance of social class in as far as health inequalities and change are concerned.
Despite the fact that some literatures show that there no significant correlation between health inequalities and poverty/deprivation, one cannot ignore the need to improve the health of those with the highest degree of deprivation. The approach to addressing health inequalities in the UK should be comprehensive in that it focuses on various possible causes of these inequalities.
This will aid in developing the comprehensive approach required to address these causes. Therefore, there is need to include determination of relevant polices that should be put to work so as to improve the overall socioeconomic status of the population.
A reduction in mortality rate between the extremes in social distribution is the not the only way through which health inequalities can be addressed. Rather it is one facet of social inequality on health inequalities. Irrespective of the rhetorical commitment in addressing issues related to health inequalities, it is a great issue that continues to persist in the UK society.
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- http://orcid.org/0000-0002-1294-6851 Clare Bambra 1 ,
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This essay examines the implications of the COVID-19 pandemic for health inequalities. It outlines historical and contemporary evidence of inequalities in pandemics—drawing on international research into the Spanish influenza pandemic of 1918, the H1N1 outbreak of 2009 and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates. It then examines how these inequalities in COVID-19 are related to existing inequalities in chronic diseases and the social determinants of health, arguing that we are experiencing a syndemic pandemic . It then explores the potential consequences for health inequalities of the lockdown measures implemented internationally as a response to the COVID-19 pandemic, focusing on the likely unequal impacts of the economic crisis. The essay concludes by reflecting on the longer-term public health policy responses needed to ensure that the COVID-19 pandemic does not increase health inequalities for future generations.
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This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the COVID-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.
http://dx.doi.org/10.1136/jech-2020-214401
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INTRODUCTION
In 1931, Edgar Sydenstricker outlined inequalities by socio-economic class in the 1918 Spanish influenza epidemic in America, reporting a significantly higher incidence among the working classes. 1 This challenged the widely held popular and scientific consensus of the time which held that ‘the flu hit the rich and the poor alike’. 2 In the COVID-19 pandemic, there have been similar claims made by politicians and the media - that we are ‘all in it together’ and that the COVID-19 virus ‘does not discriminate’. 3 This essay aims to dispel this myth of COVID-19 as a socially neutral disease, by discussing how, just as 100 years ago, there are inequalities in COVID-19 morbidity and mortality rates—reflecting existing unequal experiences of chronic diseases and the social determinants of health. The essay is structured in three main parts. Part 1 examines historical and contemporary evidence of inequalities in pandemics—drawing on international research into the Spanish influenza pandemic of 1918, the H1N1 outbreak of 2009 and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates. Part 2 examines how these inequalities in COVID-19 are related to existing inequalities in chronic diseases and the social determinants of health, arguing that we are experiencing a syndemic pandemic . In Part 3, we explore the potential consequences for health inequalities of the lockdown measures implemented internationally as a response to the COVID-19 pandemic, focusing on the likely unequal impacts of the economic crisis. The essay concludes by reflecting on the longer-term public health policy responses needed to ensure that the COVID-19 pandemic does not increase health inequalities for future generations.
PART 1. HISTORICAL AND CONTEMPORARY EVIDENCE OF INEQUALITIES IN PANDEMICS
More recent studies have confirmed Sydenstricker’s early findings: there were significant inequalities in the 1918 Spanish influenza pandemic. The international literature demonstrates that there were inequalities in prevalence and mortality rates: between high-income and low-income countries, more and less affluent neighbourhoods, higher and lower socio-economic groups, and urban and rural areas. For example, India had a mortality rate 40 times higher than Denmark and the mortality rate was 20 times higher in some South American countries than in Europe. 4 In Norway, mortality rates were highest among the working-class districts of Oslo 5 ; in the USA, they were highest among the unemployed and the urban poor in Chicago, 6 and across Sweden, there were inequalities in mortality between the highest and lowest occupational classes—particularly among men. 7 In contrast, countries with smaller pre-existing social and economic inequalities, such as New Zealand, did not experience any socio-economic inequalities in mortality. 8 9 An urban–rural effect was also observed in the 1918 influenza pandemic whereby, for example, in England and Wales, the mortality was 30%–40% higher in urban areas. 10 There is also some evidence from the USA that the pandemic had long-term impacts on inequalities in child health and development. 11
Several studies have also demonstrated inequalities in the 2009 H1N1 influenza pandemic. For example, globally, Mexico experienced a higher mortality rate than that in higher-income countries. 12 In terms of socio-economic inequalities, themortality rate from H1N1 in the most deprived neighbourhoods of England was three times higher than in the least deprived. 13 It was also higher in urban compared to rural areas. 13 Similarly, a Canadian study in Ontario found that hospitalisation rates for H1N1 were associated with lower educational attainment and living in a high deprivation neighbourhood. 14 Another study found positive associations between people with financial issues (eg, financial barriers to healthcare access) and influenza-like illnesses during the 2009 H1N1 pandemic in the USA. 15 Various studies on cyclical winter influenza in North America have also found associations between mortality, morbidity and symptom severity and socio-economic status among adults and children. 16 17
Just as in 1918 and 2009, evidence of social inequalities is already emerging in relation to COVID-19 from Spain, the USA and the UK. Intermediate data published by the Catalonian government in Spain suggest that the rate of COVID-19 infection is six or seven times higher in the most deprived areas of the region compared to the least deprived. 18 Similarly, in preliminary USA analysis, Chen and Krieger (2020) found area-level socio-spatial gradients in confirmed cases in Illinois and positive test results in New York City, with dramatically increased risk of death observed among residents of the most disadvantaged counties. 19 With regard to ethnic inequalities in COVID-19, data from England and Wales have found that people who are black, Asian and minority ethnic (BAME) accounted for 34.5% of 4873 critically ill COVID-19 patients (in the period ending April 16, 2020) and much higher than the 11.5% seen for viral pneumonia between 2017 and 2019. 20 Only 14% of the population of England and Wales are from BAME backgrounds. Even more stark is the data on racial inequalities in COVID-19 infections and deaths that are being released by various states and municipalities in the USA. For example, in Chicago (in the period ending April 17, 2020), 59.2% of COVID-19 deaths were among black residents and the COVID-19 mortality rate for black Chicagoans was 34.8 per 100 000 population compared to 8.2 per 100 000 population among white residents. 21 There will likely be an interaction of race and socio-economic inequalities, demonstrating the intersectionality of multiple aspects of disadvantage coalescing to further compound illness and increase the risk of mortality. 22
PART 2. THE SYNDEMIC OF COVID-19, CHRONIC DISEASE AND THE SOCIAL DETERMINANTS OF HEALTH
The COVID-19 pandemic is occurring against a backdrop of social and economic inequalities in existing non-communicable diseases (NCDs) as well as inequalities in the social determinants of health. Inequalities in COVID-19 infection and mortality rates are therefore arising as a result of a syndemic of COVID-19, inequalities in chronic diseases and the social determinants of health. The prevalence and severity of the COVID-19 pandemic is magnified because of the pre-existing epidemics of chronic disease—which are themselves socially patterned and associated with the social determinants of health. The concept of a syndemic was originally developed by Merrill Singer to help understand the relationships between HIV/AIDS, substance use and violence in the USA in the 1990s. 23 A syndemic exists when risk factors or comorbidities are intertwined, interactive and cumulative—adversely exacerbating the disease burden and additively increasing its negative effects: ‘A syndemic is a set of closely intertwined and mutual enhancing health problems that significantly affect the overall health status of a population within the context of a perpetuating configuration of noxious social conditions’ [24 p13]. We argue that for the most disadvantaged communities, COVID-19 is experienced as a syndemic—a co-occurring, synergistic pandemic that interacts with and exacerbates their existing NCDs and social conditions ( figure 1 ).
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The syndemic of COVID-19, non-communicable diseases (NCDs) and the social determinants of health (adapted from Singer 23 and Dahlgren and Whitehead 25 ).
Minority ethnic groups, people living in areas of higher socio-economic deprivation, those in poverty and other marginalised groups (such as homeless people, prisoners and street-based sex workers) generally have a greater number of coexisting NCDs, which are more severe and experienced at at a younger age. For example, people living in more socio-economically disadvantaged neighbourhoods and minority ethnic groups have higher rates of almost all of the known underlying clinical risk factors that increase the severity and mortality of COVID-19, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), heart disease, liver disease, renal disease, cancer, cardiovascular disease, obesity and smoking. 26–29 Likewise, minority ethnic groups in Europe, the USA and other high-income countries experience higher rates of the key COVID-19 risk factors, including coronary heart disease and diabetes. 28 Similarly, the Gypsy/Roma community—one of the most marginalised minority groups in Europe—has a smoking rate that is two to three times the European average and increased rates of respiratory diseases (such as COPD) and other COVID-19 risk factors. 29
These inequalities in chronic conditions arise as a result of inequalities in exposure to the social determinants of health: the conditions in which people ‘live, work, grow and age’ including working conditions, unemployment, access to essential goods and services (eg, water, sanitation and food), housing and access to healthcare. 25 30 By way of example, there are considerable occupational inequalities in exposure to adverse working conditions (eg, ergonomic hazards, repetitive work, long hours, shift work, low wages, job insecurity)—they are concentrated in lower-skill jobs. These working conditions are associated with increased risks of respiratory diseases, certain cancers, musculoskeletal disease, hypertension, stress and anxiety. 31 In addition to these long-term exposures, inequalities in working conditions may well be impacting the unequal distribution of the COVID-19 disease burden. For example, lower-paid workers (where BAME groups are disproportionately represented)—particularly in the service sector (eg, food, cleaning or delivery services)—are much more likely to be designated as key workers and thereby are still required to go to work and rely on public transport for doing so. All these increase their exposure to the virus.
Similarly, access to healthcare is lower in disadvantaged and marginalised communities—even in universal healthcare systems. 32 In England, the number of patients per general practitioner is 15% higher in the most deprived areas than that in the least deprived areas. 33 Medical care is even more unequally distributed in countries such as the USA where around 33 million Americans—from the most disadvantaged and marginalised groups—have insufficient or no healthcare insurance. 27 This reduced access to healthcare—before and during the outbreak—contributes to inequalities in chronic disease and is also likely to lead to worse outcomes from COVID-19 in more disadvantaged areas and marginalised communities. People with existing chronic conditions (eg, cancer or cardiovascular disease (CVD)) are less likely to receive treatment and diagnosis as health services are overwhelmed by dealing with the pandemic.
Housing is also an important factor in driving health inequalities. 34 For example, exposure to poor quality housing is associated with certain health outcomes, for example, damp housing can lead to respiratory diseases such as asthma while overcrowding can result in higher infection rates and increased risk of injury from household accidents. 34 Housing also impacts health inequalities materially through costs (eg, as a result of high rents) and psychosocially through insecurity (eg, short-term leases). 34 Lower socio-economic groups have a higher exposure to poor quality or unaffordable, insecure housing and therefore have a higher rate of negative health consequences. 35 These inequalities in housing conditions may also be contributing to inequalities in COVID-19. For example, deprived neighbourhoods are more likely to contain houses of multiple occupation and smaller houses with a lack of outside space, as well as have higher population densities (particularly in deprived urban areas) and lower access to communal green space. 27 These will likely increase COVID-19 transmission rates—as was the case with H1N1 where strong associations were found with urbanity. 13
The social determinants of health also work to make people from marginalised communities more vulnerable to infection from COVID-19—even when they have no underlying health conditions. Decades of research into the psychosocial determinants of health have found that the chronic stress of material and psychological deprivation is associated with immunosuppression. 36 Psychosocial feelings of subordination or inferiority as a result of occupying a low position on the social hierarchy stimulate physiological stress responses (eg, raised cortisol levels), which, when prolonged (chronic), can have long-term adverse consequences for physical and mental health. 37 By way of example, studies have found consistent associations between low job status (eg, low control and high demands), stress-related morbidity and various chronic conditions including coronary heart disease, hypertension, obesity, musculoskeletal conditions, and psychological ill health. 38 Likewise, there is increasing evidence that living in disadvantaged environments may produce a sense of powerlessness and collective threat among residents, leading to chronic stressors that, in time, damage health. 39 Studies have also confirmed that adverse psychosocial circumstances increase susceptibility—influencing the onset, course and outcome of infectious diseases—including respiratory diseases like COVID-19. 40
PART 3. THE GREAT LOCKDOWN: THE COVID-19 ECONOMIC CRISIS AND HEALTH INEQUALITIES
The impact of COVID-19 on health inequalities will not just be in terms of virus-related infection and mortality, but also in terms of the health consequences of the policy responses undertaken in most countries. While traditional public health surveillance measures of contact tracing and individual quarantine were successfully pursued by some countries (most notably by South Korea and Germany) as a way of tackling the virus in the early stages, most other countries failed to do so, and governments worldwide were eventually forced to implement mass quarantine measures—in the form of lockdowns. These state-imposed restrictions—usually requiring the government to take on emergency powers—have been implemented to varying levels of severity, but all have in common a significant increase in social isolation and confinement within the home and immediate neighbourhood. The aims of these unprecedented measures are to increase social and physical distancing and thereby reduce the effective reproduction number (eR0) of the virus to less than 1. For example, in the UK, individuals were only allowed to leave the home for one of four reasons (shopping for basic necessities, exercise, medical needs, travelling for work purposes). Following Wuhan province in China, most of the lockdowns have been implemented for 8 to 12 weeks.
The immediate pathways through which the COVID-19 emergency lockdowns are likely to have unequal health impacts are multiple—ranging from unequal experiences of lockdown (eg, due to job and income loss, overcrowding, urbanity, access to green space, key worker roles), how the lockdown itself is shaping the social determinants of health (eg, reduced access to healthcare services for non-COVID-19 reasons as the system is overwhelmed by the pandemic) and inequalities in the immediate health impacts of the lockdown (eg, in mental health and gender-based violence). However, arguably, the longer-term and largest consequences of the ‘great lockdown’ for health inequalities will be through political and economic pathways ( figure 1 ). The world economy has been severely impacted by COVID-19—with almost daily record stock market falls, oil prices have crashed and there are record levels of unemployment (eg, 5.2 million people filed for unemployment benefit in just 1 week in April 2020 in the USA), despite the unprecedented interventionist measures undertaken by some governments and central banks—such as the £300 billion injection by the UK government to support workers and businesses. The pandemic has slowed China’s economy with a predicted loss of $65 billion as a minimum in the first quarter of 2020. Economists fear that the economic impact will be far greater than the financial crisis of 2007/2008, and they say that it is likely to be worse in depth than the Great Depression of the 1930s. Just like the 1918 influenza pandemic (which had severe impacts on economic performance and increased poverty rates), the COVID-19 crisis will have huge economic, social and—ultimately—health consequences.
Previous research has found that sudden economic shocks (like the collapse of communism in the early 1990s and the global financial crisis (GFC) of 2008 41 ) lead to increases in morbidity, mental ill health, suicide and death from alcohol and substance use. For example, following the GFC, worldwide an excess of suicides were observed in the USA, England, Spain and Ireland. 42 There is also evidence of other increases in poor mental health after the GFC including self-harm and psychiatric morbidity. 41 42 These health impacts were not shared equally though—areas of the UK with higher unemployment rates had greater increases in suicide rates and inequalities in mental health increased with people living in the most deprived areas experiencing the largest increases in psychiatric morbidity and self-harm. 43 Further, unemployment (and its well-established negative health impacts in terms of morbidity and mortality 38 ) is disproportionately experienced by those with lower skills or who live in less buoyant local labour markets. 27 So, the health consequences of the COVID-19 economic crisis are likely to be similarly unequally distributed—exacerbating heath inequalities.
However, the effects of recessions on health inequalities also vary by public policy response with countries such as the UK, Greece, Italy and Spain who imposed austerity (significant cuts in health and social protection budgets) after the GFC experiencing worse population health effects than those countries such as Germany, Iceland and Sweden who opted to maintain public spending and social safety nets. 41 Indeed, research has found that countries with higher rates of social protection (such as Sweden) did not experience increases in health inequalities during the 1990s economic recession. 44 Similarly, old-age pensions in the UK were protected from austerity cuts after the GFC and research has suggested that this prevented health inequalities increasing amongst the older population. 45 These findings are in keeping with previous studies of the effects of public sector and welfare state contractions and expansions on trends in health inequalities in the UK, USA and New Zealand. 27 46–49 For example, inequalities in premature mortality and infant mortality by income and ethnicity in the USA decreased during the period of welfare expansion in the USA (‘war on poverty’ era 1966 to 1980), but they increased again during the Reagan–Bush period (1980–2002) when welfare services and healthcare coverage were cut. 46 Similarly, in England, inequalities in infant mortality rates reduced as child poverty decreased in a period of public sector and welfare state expansion (from 2000 to 2010), 47 but increased again when austerity was implemented and child poverty rates increased (from 2010 to 2017). 48
So this essay makes for grim reading for researchers, practitioners and policymakers concerned with health inequalities. Historically, pandemics have been experienced unequally with higher rates of infection and mortality among the most disadvantaged communities—particularly in more socially unequal countries. 8 9 Emerging evidence from a variety of countries suggests that these inequalities are being mirrored today in the COVID-19 pandemic. Both then and now, these inequalities have emerged through the syndemic nature of COVID-19—as it interacts with and exacerbates existing social inequalities in chronic disease and the social determinants of health. COVID-19 has laid bare our longstanding social, economic and political inequalities - even before the COVID-19 pandemic, life expectancy amongst the poorest groups was already declining in the UK and the USA and health inequalities in some European countries have been increasing over the last decade. 50 It seems likely that there will be a post-COVID-19 global economic slump—which could make the health equity situation even worse, particularly if health-damaging policies of austerity are implemented again. It is vital that this time, the right public policy responses (such as expanding social protection and public services and pursuing green inclusive growth strategies) are undertaken so that the COVID-19 pandemic does not increase health inequalities for future generations. Public health must ‘win the peace’ as well as the ‘war’.
Acknowledgments
We would like to thank Chris Orton from the Cartographic Unit, Department of Geography, Durham University, for his assistance with the graphics for figure 1 .
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Twitter Clare Bambra @ProfBambra.
Funding CB is a senior investigator in the National Institute for Health Research (NIHR) ARC North East and North Cumbria, NIHR Policy Research Unit in Behavioural Science, NIHR School of Public Health Research, the UK Prevention Research Partnership SIPHER: Systems science in Public Health and Health Economics Research consortium, and the Norwegian Research Council Centre for Global Health Inequalities Research. JF is a senior investigator in the NIHR ARC East of England. FM is a senior investigator in the NIHR Policy Research Unit in Ageing and Frailty. The views expressed in this publication are those of the authors and not necessarily those of the funders.
Competing interests We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.
Patient consent for publication Not required.
Data sharing statement Data sharing not applicable as no datasets generated and/or analysed for this study.
Provenance and peer review Not commissioned; internally peer reviewed.
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Inequalities in Health Care Essay
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