Inequality impact: life or death

Poverty and inequality are among the most pressing and persistent problems in US society, and the COVID-19 pandemic underscores how perilous—and deadly—inaction on these issues can be. People with low incomes work essential jobs in transportation, food production and delivery, health care, and other service-oriented industries that put them at risk for contracting COVID-19 and may compound existing health, social, and economic challenges they faced even before the pandemic. Additionally, about half of these low-wage workers are non-White and are more likely to experience barriers to health care and suffer from comorbidities than their White counterparts because of systemic racism.1 Beyond occupational risk, people with low incomes suffer from more comorbidities that heighten the risk of infection and hospitalization. Data from Medicare, for example, showed that low-income older adults were more likely to be diagnosed with and hospitalized for COVID-19 (Figure 1)2; once hospitalized for COVID-19, older adults and those with certain underlying medical conditions face a mortality risk of 30% or higher.3 The COVID-19 pandemic clearly shows that income inequality is a matter of life and death.

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FIGURE 1—

COVID-19 Infection and Hospitalization Rates Among Medicare Beneficiaries: United States, January 1–November 21, 2020

Note. This figure shows COVID-19 infection and hospitalization rates per 100 000 Medicare beneficiaries by age group as reported by the Centers for Medicare & Medicaid Services.2 More than 12.2 million primarily low-income Medicare beneficiaries also qualify for their state’s Medicaid program and receive either full or partial benefits. At any age, dual-eligible beneficiaries experience higher rates of COVID-19 infection and COVID-19–related hospitalizations.

In stark contrast to the experience of low-income populations, high-income individuals were significantly more likely to keep their jobs and telework after social-distancing guidelines were implemented across the country. The extremely wealthy have fared even better; estimates from advocacy organizations suggest that the wealth of US billionaires has increased by $1.1 trillion since March 2020, signifying that they have not only recovered but have become richer since the pandemic started.4 This finding clearly illustrates how income and wealth inequality is perpetuated in the United States. Meanwhile, tens of millions are still unemployed, with some of those receiving unemployment benefits, and the poverty rate increased from 9.3% in June 2020 to 11.8% in December 2020, with the steepest increases among Black individuals, children, and people with a high school education or less.5 , 6 Without deliberate interventions, economic recovery from the pandemic will surely be hardest for the most vulnerable and marginalized populations.

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INCOME SHAPES HEALTH AND LONGEVITY

Because income is a significant, well-documented determinant of health, the effects of low income and income inequality are reflected in population health. Referred to as a “cause of causes” or “fundamental cause” of health outcomes, income shapes the resources at our disposal, the disease risks we are exposed to, and our ability to mitigate these risks.7 Decades of research have shown that low-income people have poorer self-reported health and higher rates of communicable and noncommunicable diseases and injuries because of a constellation of risk factors, such as smoking, unhealthy diet associated with food poverty and insecurity, stress and anxiety, and unemployment and job insecurity, among others.8 , 9 Income influences health throughout a person’s life course; for example, low-income mothers are more likely to have babies with low birth weight, which, in turn, is associated with negative physical and mental health outcomes.10 Among older adults, low wealth—a more appropriate measure of socioeconomic position at older ages than income—is associated with a more marked decline in physical and psychosocial functions.11

Additionally, the presence of income inequality itself has been linked to negative health outcomes. There has been a significant increase in income inequality in the United States since the 1980s following deliberate government policies to reduce tax rates and shrink social safety net programs. Today, 50% of all household income goes to the top 10% of earners, and only 13% goes to the bottom 50% of earners. Similarly, 31% of household wealth goes to the top 1% of households, and only 2% of household wealth is held by the bottom 50% of households.12 , 13 It is important to note that racism has played a significant role in creating the income and wealth differential in the United States; in 2019, the typical White family had eight times more wealth than a typical Black family ($184 000 vs $23 000).12

Increasing income inequality has coincided with disparities in health and longevity. For example, societies with wider income inequalities have been found to have higher rates of interpersonal violence and mental illness.14 There has also been an increase in gaps in survival between high- and low-income individuals, with top earners increasing their life expectancy and low-income individuals decreasing theirs.15 Although inequality is an ecological phenomenon, one potential mechanism for how it affects individuals is through a psychosocial pathway; research suggests that inequality is a “social stressor” that causes social anxiety and chronic stress and erodes social support and cohesion, which are essential health resources.14 , 15

The effect of income on health is arguably most consequential in its role in extending life, and there is strong evidence for the negative, nonlinear association between income and mortality in the United States. For example, three studies using distinct longitudinal panel data have consistently shown that adults with higher personal or family incomes face lower rates of all-cause mortality.16–18 One of these studies estimates that after adjusting for race and age, people in the highest income decile (≥ $105 500 per year in 2019 dollars) have incident mortality rates that are 38% lower than the rates of those with an average household income (approximately $52 500–$63 500 per year).

On the other hand, people in the lowest household income decile (≤ $11 500 per year) face incident mortality rates that are more than two times higher than the rates of people with average incomes. Another recent study, which used 1.4 billion tax records, showed that there is a 14.6-year life expectancy difference between males in the top 1% and the bottom 1% of the income distribution; among females, the difference is 10.1 years.19 In addition, the advantage in longevity among high-income individuals grew between 2001 and 2014. This relationship between income and mortality holds even when lifetime earnings or wealth are used as measures of exposure. Additionally, sudden decreases in income or wealth are associated with a higher risk of death.20

Income’s effect on health often follows a “social gradient,” or stepwise pattern, whereby people with incrementally higher incomes fare better than their lower-income counterparts.7 This pattern is often cited as a rationale for paying attention to people across the income distribution because a narrow focus on people with very low incomes would miss those in the middle, whose health is also negatively affected by inequality. Although a gradient is observed between income and mortality, income gains among people with high incomes provide lower returns in longevity than do income gains among people with low incomes. For example, one study found that increasing one’s annual income from $14 000 to $20 000 (a $6000 increase) would have the same benefit in life expectancy as increasing one’s annual income from $161 000 to $224 000 (a $63 000 increase).19 In another study, individuals with annual household incomes below $49 100 (in 2019 dollars) had the greatest reduction in mortality risk from an increase in income; the benefit among people with higher household incomes was smaller and not statistically significant.18

These findings highlight the importance of broad strategies that will benefit people across the income distribution; at the same time, the diminishing returns of increased income on mortality also emphasize that people with the lowest incomes have the most to gain from policy interventions and should be prioritized. As one study aptly concludes, people with lower incomes are “paying with their lives to sustain high inequality.”16(p187)