The Lancet Series on ‘America: Equity and Equality in Health’

Editorial: America, all things not being equal

The Lancet, April 8, 2017

In an effort to better understand the conditions and mechanisms driving health disparities in the USA, this week, The Lancet breaks ground once again by publishing, America: Equity and Equality in Health — a stark and dire update to the first Series — focused on appraising where the greatest discrepancies lie. Comprising five papers, the Series looks in depth at the current inequalities in the health-care system and chronicles the beneficial influence of the ACA on health-care equity as well as the continued barriers and shortcomings in providing coverage.


Inequality and the health-care system in the USA

By Samuel L Dickman, David U Himmelstein, Steffie Woolhandler

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.


The Affordable Care Act: implications for health-care equity

By Adam Gaffney, Danny McCormick

Although the ACA improved coverage and access—particularly for poorer Americans, women, and minorities — its overall impact was modest in comparison with the gaps present before the law’s implementation. We discuss proposals for change from opposite sides of the political spectrum, together with their potential impact on health equity.


Structural racism and health inequities in the USA: evidence and interventions

By Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett

In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.


Mass incarceration, public health, and widening inequality in the USA

By Christopher Wildeman, Emily A Wang

The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries.


Population health in an era of rising income inequality: USA, 1980–2015

By Jacob Bor, Gregory H Cohen, Sandro Galea

Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution — ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans.


Comment: An agenda to fight inequality

By Bernie Sanders

The USA is one of the richest countries in the world, but that reality means very little for most people because so much of that wealth is controlled by a tiny sliver of Americans. During the past 35 years, there has been a massive transfer of wealth away from the middle class and the poor to the top 0·1% of the US population.

Such inequality continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue.

The USA’s dysfunctional health-care system is a major contributor to the nation’s health inequalities. Today, the US health-care system too often serves to enrich wealthy investors and executives, while impoverishing, and even bankrupting, many working families.

Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. The USA has the most expensive, bureaucratic, wasteful, and ineffective health-care system in the world.16 Medicare- for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions of dollars in medical costs.

Making sure that every citizen has the right to child care, health care, a college education, and a secure retirement is not a radical idea. It is as American as apple pie. It will allow us to realise the ideals of the USA: that all of us are created equal — that we all have the right to life, liberty, and the pursuit of happiness.


Profile: David Himmelstein and Steffe Woolhandler: advocates for an equitable US health system

By Richard Lane

With President Donald Trump’s failure to get the American Health Care Act (AHCA) as far as a vote in Congress, are they optimistic for the future? “The AHCA’s defeat has certainly buoyed our spirits. Obamacare expanded coverage, but its adherence to a market-based approach hobbled the reform, leaving it open to Trump’s attacks”, says Woolhandler. “The surging opposition that triggered the collapse of the Republican plan signals the broad support for a non-market alternative that can create a new opening for single payer, so yes, we have some grounds for optimism,” Himmelstein says.



By Don McCanne, M.D.

For those looking for something to read this weekend, you couldn’t do better than this Lancet series on the lack of equity and equality in America and its impact on health care. If you don’t have time, at least you can get the gist of the theme by reading these relatively short excerpts. Also, the articles are well worth saving as a reference source to use in our advocacy for expanding health care justice throughout America.