Health Care Issues

Healthy And Wealthy

Epidemiologists tell us that those of higher income and social status are likely to be healthier -- physically and mentally -- than those on the lower social and economic rungs of the ladder, and they don't know why.

  • One of the first researchers to note this phenomenon was Sir Douglas Black -- a former president of the Royal College of Physicians -- whose 1980 report was based on statistical studies comparing illnesses and social class in England and Wales.

  • Experts say the differences are not due to better availability of medical care to the wealthy, since socio-economic differences exist for diseases that are not amenable to treatment.

  • The "Whitehall Studies" of well-off, white-collar British civil servants of some years back revealed that instances of illnesses decreased as one traced health from the lowliest clerk up to senior administrators -- a signal that poverty is not the cause, since even the clerk was receiving sufficient income to afford proper health care.

  • Life-style differences seem to offer no clue, since most of the social inequality in coronary heart disease remains even after such differences are taken into account.

Source: Richard A. Shweder (University of Chicago), "It's Called Poor Health for a Reason," New York Times, March 9, 1997.

Chronically Ill Elderly And Poor
Do Worse In HMOs

The chronically ill elderly and poor tend to fare worse in health maintenance organizations (HMOs), which pay a flat fee per patient, than under conventional fee-for-service (FFS) care, according to a recent study in the Journal of the American Medical Association.

Researchers studied the health of 2,235 patients with chronic conditions in three cities over a four-year period. They scored changes in the health status of patients in the sample using standard measures. The patients studied were adults who had such illnesses as high blood pressure, diabetes and congestive heart failure. The study found that:

  • The elderly were much more likely to experience health declines than other groups, but income differences among the elderly made little difference in outcomes.

  • Among elderly patients covered by Medicare, 54 percent of those in HMOs experienced a decline in physical health compared to 28 percent of those in fee-for-service plans.

  • For low-income patients, only 22 percent of those in HMOs showed improvements in physical health, compared to 57 percent of those in FFS plans.

  • Statistically significant differences in health status between HMO and FFS patients in either group were found at the end of four years but not one year -- suggesting that differences in care received may take years to become apparent.

The study concluded that younger, higher-income patients in the sample tended to fare equally well under both types of care.

A recent survey of Medicare patients conducted for the Physician Payment Review Commission seems to support these findings. It found that those enrolled in HMOs were three times more likely to report some problem with access to care than those in traditional FFS Medicare -- 16 percent of HMO enrollees versus 3 percent for FFS patients.

Source: John E. Ware et al., "Differences in 4-Year Health Outcomes for Elderly and Poor, Chronically Ill Patients Treated in HMO and Fee-for-Service Systems," Journal of the American Medical Association, October 2, 1996, and Sharon McIIrath, "New Restrictions on HMOs?" American Medical News, December 2, 1996.

Poverty Impacts Health

Prolonged economic hardship leads to poorer physical and psychological health and difficulties with cognitive functioning, concludes a study sponsored by the National Institute on Aging and published in the New England Journal of Medicine.

It is well established that low-income individuals generally have poorer health than the nonpoor, but most previous research measured income at only one time. This study used income and health data collected from a representative sample of adults in Alameda County, Calif., in 1965, 1974 and 1983. Using data over time allowed researchers to determine the cumulative effects of economic hardship.

Researchers found that previous periods of economic hardship -- defined as years in which total household income was less than 200 percent of the federal poverty level -- were a good predictor of the health status among those still alive in 1994. For instance:

  • Study participants who reported economic hardship for all three years had 3.79 times greater odds of having difficulties with activities of daily living in 1994 than those who had no history of economic hardship.

  • They were also 3.2 times more likely to suffer from depression in 1994.

  • And they were 4.6 times more like to have trouble remembering names or where things were placed.

People who suffered hardship in just one or two of the periods reported less severe consequences, but the impact worsened as the number of episodes increased, suggesting what researchers called a dose-response effect of low income and social status.

Looking only at a subgroup of people who were young and healthy in 1965, researchers found that those who had more economic hardship had worse physical functioning in 1994, suggesting that illness was an effect of economic hardship, rather than the cause.

Source: John W. Lynch, George A. Kaplan and Sarah J. Shema, "Cumulative Impact of Sustained Economic Hardship on Physical, Cognitive, Psychological, and Social Functioning," New England Journal of Medicine, December 25, 1997.

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