POVERTY AND HEALTH

People with low incomes, particularly those who live in poverty, face particular challenges in maintaining their health. They are more likely than those with higher incomes to become ill, and to die at younger ages. They are also more likely to live in poor environmental situations with limited health care resources—factors that can compromise health status and access to care. Public programs play a vital role in helping to reduce disparities in health by income by supporting health initiatives targeted at those with low incomes and maintaining a safety net of health and social services for the poor.

POVERTY IN THE UNITED STATES

The United States is one of the wealthiest nations in the world, yet a significant portion of the population still lives in poverty. Though the poverty rate declined during the 1990s due to a strong economy, 11.8 percent of Americans—over 32 million people—lived below the poverty level in 1999. Calculated to assess the cost of food and basic expenses by family size, the federal poverty level was a little over $17,000 a year for a family of four in 1999. Many of America's poor are living far below the poverty level on incomes that barely exceed $10,000. In addition to the poor, another 50 million people are "near poor" and have incomes between poverty and twice the poverty level.

The problem of poverty in America is even more alarming when looking at particularly vulnerable populations (see Figure 1). According to the Census Bureau, in 1999:

• 16.9 percent of all children and 18 percent of children under age six lived in poverty, versus 10 percent of adults.

Figure 1

• Minority racial and ethnic groups are much more likely to live in poverty—23.6 percent of blacks and 22.8 percent of Hispanics lived below the poverty level, versus 7.7 percent of whites.
• Female-headed households (with no husband present) are much more likely than married couple families to live in poverty (27.8% versus 4.8%), with black and Hispanic female-headed households having the highest poverty rates (39.3% and 38.8%, respectively).

Public assistance helps many of the lowest-income families and individuals meet their most basic financial and health needs. Social Security, for example, provides financial assistance to workers and their families in retirement, as well as to some disabled individuals, enabling those who are no longer working to maintain an income. Since its enactment in 1935, this program has helped reduce poverty among the elderly and disabled, and today less than 10 percent of the elderly live in poverty. Many low-income families have also been helped by cash assistance (also called "welfare"), formerly under the Aid to Families with Dependent Children (AFDC) program and, since 1996, under the Temporary Assistance for Needy Families (TANF) program. While this assistance is an essential source of support for millions of families, the populations that are the targets for such assistance—mainly children and single-headed households—still have some of the highest poverty rates in the nation. Poverty persists in these groups for many reasons, including low benefit levels in welfare and restrictive eligibility levels that leave most workers, even those working at minimum wage jobs, ineligible for assistance.

While the poverty statistics for the United States are alarming, the problem of poverty around the world is even more dire. According to the World Bank, the average income in the world's wealthiest countries (which includes the United States) is thirty-seven times that in the poorest nations. This differential exists because poverty in developing nations is not only more prevalent, it is also significantly deeper—2.8 billion people in the world live on less than $2 a day, and 1.2 billion live on less than $1 a day. Poverty touches all areas of the world, though the most impoverished conditions are found in South Asia, sub-Saharan Africa, and East Asia and the Pacific regions. People living in the world's poorest nations are faced not only with trying to afford food, shelter, and clothing, but also with severe malnutrition, living without basic sanitation or clean water, and a lack of access to basic education.

HEALTH AND POVERTY

The impact of poverty on health is a key focus of public health. Studies have firmly established that those with low incomes have lower health status than those with higher incomes (see Figure 2). In Health, United States, 1998, the United States Department of Health and Human Services highlighted many of the disparities in health status by income and documented a stairstep pattern of worsening outcomes from rich to poor that holds true for almost all risk factors, diseases, and causes of death, and persists within racial and ethnic groups. Poor Americans are significantly more likely than those with high incomes to have health risk factors that include smoking, being overweight, and having a sedentary lifestyle. However, they also use less health care than most Americans and are less likely than the nonpoor to have had a recent physician contact, receive preventive care such as immunizations or cancer screening, or to avoid hospitalization for serious conditions by receiving

Figure 2

preventive, office-based care. People living in poverty have a higher prevalence of disability and chronic illness and shorter life expectancy than those at higher income levels.

Internationally, the relationship between income and health is even more striking. In poor nations, up to 20 percent of children die before the age of five (versus less than 1% in richer countries), and 50 percent of children are malnourished (versus less than 5% in wealthier nations). Maternal mortality rates are also higher in poor nations. Life expectancy—one of the most revealing indicators of health status—is sixteen years shorter for men and twenty years shorter for women in poor countries than in high-income countries.

The relationship between poverty and health is complex. Many factors play into this link, including poor environmental conditions, low education levels and awareness of needed medical care, financial barriers in accessing health services, and a lack of resources necessary to maintain good health status. As Figure 3 shows, people in poverty live on very stretched incomes and have difficulty meeting day-to-day costs of living, leaving little room in their limited budget for anything beyond the essentials of food and shelter. Low-income Americans are more likely to live in older homes, which—particularly in the inner city—may expose them to lead paint, which causes developmental problems in children. People in poverty may have limited

Figure 3

budgets for food and may only be able to afford inexpensive foods, which tend to be processed, fatty, and lacking important nutrients. And low-income Americans may not be able to access preventive, acute, or long-term medical care when they need it.

Lack of access to medical care and insurance to help cover the costs of health care compromises the ability of many low-income individuals to maintain their health. Poor access to care stems from many factors, including lack of providers in low-income areas, transportation problems in getting to providers, discrimination by providers, and lack of financial means and health insurance to help pay for care. Poor and near-poor Americans are much more likely than higher-income Americans to lack insurance (see Figure 4) and together account for nearly two-thirds of all uninsured people in the nation. Low-income workers are less likely than those with high incomes to be offered insurance as a fringe benefit, and a typical health insurance policy—which costs on average six thousand dollars a year for a family—is often prohibitively expensive or unavailable to the poor. Medicaid provides coverage for many poor and low-income Americans, but limits on eligibility—particularly for adults—leave many outside its reach. With no coverage, the poor are forced to forgo or delay care until absolutely necessary, often seeking assistance only when their illness has progressed to a serious state.

Figure 4

Conditions of everyday life for the poor, such as exposure to hazardous environmental and occupational conditions (e.g., neighborhood violence or pollution) or employment in dangerous, stressful jobs that offer few fringe benefits, also influence their health care. Other "third factor" explanations look to the adverse health effects of unemployment (such as depression) or the connection between educational attainment and positive health behavior to understand why income is related to health status. In recent years, a growing body of research has looked to psychosocial factors to explain that it is not always income per se that affects health, but rather the social stratification or level of income inequality in society in general that affects health status.

ADDRESSING POVERTY AND HEALTH

Public health plays a central role in addressing the effects of poverty on health status and minimizing the disparities in health by income. Public health initiatives aimed at protecting the health of the population have been especially important in reducing communicable diseases and providing preventive health services to low-income populations. Providing immunizations and well-baby care to children, improving sanitation and reducing environmental hazards, treating and controlling tuberculosis, and combating sexually transmitted diseases are examples of public health functions that directly affect the health and well-being of people in poverty.

Public health efforts also aim to address disparities in health by income by focusing resources in underserved areas. The U.S. federal government funds a network of community health centers, migrant and rural health centers, public housing clinics, school-based clinics, and health clinics for the homeless to provide medical care in areas with high rates of uninsurance and an undersupply of providers. Similarly, the National Health Service Corps increases access to provider services by helping to place physicians in communities with vulnerable populations. Other public health services are focused on specific diseases, particularly infectious diseases that may thrive in impoverished areas (such as tuberculosis), or increasing immunization against communicable disease. Public programs in underserved areas also provide nonmedical services that facilitate improvements in the health of low-income families, including Head Start (which provides early day care), public housing, environmental efforts aimed at cleaning up neighborhoods through lead abatement, facilities improvement, or pollution control; and nutrition programs such as school lunch assistance and the Women, Infants, and Children (WIC) feeding program.

One of the largest and most important public programs to improve access to health care for the low-income population is Medicaid, a federal-state partnership that finances health and long-term care insurance for over 40 million low-income Americans. Prior to Medicaid's passage in 1965, the poor were essentially outside mainstream medical care, relying on the charity of physicians and hospitals, or on public hospitals and clinics, for their care and often facing discrimination in their attempts to access services. Medicaid has reshaped the availability and provision of care to the poor and helped to improve health status, access to care, and satisfaction with the health care system among the poor. The value of Medicaid is underscored by the contrast in outcomes between the poor with Medicaid and the uninsured poor, where studies consistently show that the uninsured lag

Figure 5

well behind those with Medicaid, while those with Medicaid fare comparably to the privately insured (see Figure 5).

Although these programs offer valuable assistance to help low-income individuals obtain necessary medical care, the deficits in access and coverage faced by the low-income population are not easily overcome. Improvements in income can make a substantial contribution to removing health differentials by income, but supplemental efforts through insurance coverage for the uninsured and support for community-based resources in underserved areas are also important components of efforts to eliminate health disparities by income.

Diane Rowland

(see also: Access to Health Services; Community and Migrant Health Centers; Economics of Health; Head Start Program; Healthy People 2010; Homelessness; Inequalities in Health; International Development of Public Health; Medicaid; Neighborhood Health Centers; Primary Care; Social Class; Social Determinants; Social Health; Uninsurance )

Bibliography

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