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[Edit: if your last name is Dowd, scroll down.]

Health care in the United States is currently a major political issue, because it is an important resource for everyone, yet different groups of people have different degrees of access to health care resources, and have different health outcomes, as well. It has been framed as an issue of social justice, because it is typically well-off people, who tend to be white, who experience the best outcomes, while less well-off people, among whom minority groups are disproportionately represented, experience poorer outcomes. Understanding some of the reasons for it can inform the political debate on this topic.

Since poverty and poor health outcomes seem to be correlated, let us first ask: how are they related? Does poverty cause poor health, or does poor health cause poverty? The answer is not perfectly simple. Poverty does carry certain health risks to it, notably risks of exposure to environmental toxins (e.g., Diesel fumes, lead) and diseases as well as a lack of ability to take preventative action (such as buying an air filter, paint-stripping and repainting, or getting a full course of vaccines). Certainly being exposed to such factors can cause poor health. However, it is also true that poor health often interferes with an individual’s ability to perform in a job, or otherwise support himself. This is especially true of chronic conditions, such as asthma or chronic mental illness, which seem to strike the poor more often (and for which quality treatments are very expensive). Hence, to some degree, poor health contributes to poverty. And, in fact, there is a positive feedback loop here: poverty leads to poor health through exposure to health threats and lack of protection; poor health interferes with the ability to support oneself; thus poverty is worsened, and the cycle begins again.

Contributing to this cycle is the structure of the health-care industry. Currently, a person seeking medical care can either buy medical services (which are very expensive) out-of-pocket, or he may purchase a health insurance policy which will pay at least part of the cost of his medical care. However, traditionally the cost of health insurance policies has been borne (largely) by employers. As the cost of medical care has increased, the cost of insuring people against medical expenses has also increased. At the same time, businesses large enough to support the cost of medical benefits have been facing increasing pressure to focus on providing profit to shareholders and goods or services to customers, which often means offering fewer benefits to employees. Health insurance is harder to come by through employers. Individually-purchased plans are also fairly expensive, especially ones with reasonable deductibles and co-pays, and government-provided health insurance (e.g., Medicare) is not accepted by many health-care providers because of its relatively low rates of reimbursement. Hence, a person needing medical attention who is under- or uninsured may be faced with huge medical bills he cannot pay. This is bad enough for wealthy people who find themselves suddenly ill; but for poorer people who had a worse chance to begin with, the debt incurred by medical needs can help to completely and permanently destroy the financial standing of someone who was doing poorly to begin with.

It would be improper, though, to suggest that the problem is only one of money. There is an issue of knowledge and social capital, as well. A person who is poor is less likely to be aware of the life-threatening dangers of letting a toothache go untreated, is less likely to be aware of the need for prenatal and perinatal care of infants, and will generally be less aware, as well as less able to access, the resources needed to maintain health. And as mentioned before, while medical coverage through employment is harder to get, of late, it is still possible; but what’s necessary for that is contacts who can offer advice or pull strings to help an individual get into that job.

Lastly, there are mental and emotional stresses that come with poverty. Constantly having to worry about how to pay for necessities, such as food, utilities, medical care, and schooling can put one’s brain into a pathological state of stress overload, which can cause health problems, encourage self-medicating behavior (drug use) and impair an individual’s ability to perform in the workplace. Also, when people are exposed to the fact that they are living in conditions substantially poorer than those of wealthier people, it distresses them. Possibly this is not surprising, but what for wealthy suburban residents is a slightly neurotic drive to keep up with the Joneses can become serious chronic emotional problems, among people who feel they have no hope of ever bettering their lot in life. It may be that one of the risks to the health especially of poor people – violent crime – may in part be driven by this despair.

There are no quick and easy solutions. The problems described in this essay are structural problems inherent in our modern economy. And, because our economy is so complex, there is an enormous number of possible solutions to the problems, which lends itself to bewilderingly complex political debates and much wheeling and dealing over who profits, who gets what he needs and who loses out. But the problem won’t go away simply through wishful thinking. The debates about health and health care may be a necessary evil, because nobody likes blather or cutthroat politics, but they are necessary.

Edit: Prof. Dowd, if you're reading this, I anticipated you.