Health Consequences of Declining Incomes

To the Editor: The Commentary by Dr Woolf¹ considers possible future health consequences of the current decline in US household income. However, declining incomes among the middle class and increasing income inequality might not, in and of themselves, have future health consequences.

Income inequalities may instead be symptoms of broader social problems that are in turn responsible for poor health outcomes. For example, the association between income inequality and health in cross-national studies disappears when controlling for educational attainment.² This suggests that problems with schools, not income inequality, may drive the association.

In addition, the burden of disease in the bottom 80% of income earners in the United States—amounting to 17.4 million quality-adjusted life-years lost annually relative to the top 20%—has little to do with purchasing power.³ This lower 80% of US residents ranks second worldwide in terms of purchasing power but has a life expectancy below that of the average Chilean.^{3 - 4}

Although it is possible to attribute these statistics to racial disparities or lifestyles, by some measures poor white Britons (despite less healthy lifestyles) appear to be healthier than wealthy white US residents.⁵ Woolf is therefore correct in noting that the problems facing the United States affect more than the 12.3% of its residents living below the poverty line. However, the problems are deeper than just loss of income.

To address both the financial well-being and health of the population, policies must move beyond an emphasis on income inequalities alone. Instead, they must focus on underlying causes. Although redistributive programs such as earned income tax credits are needed to help families stay financially afloat in the short-term, proven education interventions such as Head Start may go further toward improving health. Improved public transit and tightened emission standards are also intuitive choices for policies that both improve public health and reduce inequalities. Woolf rightly calls for a new “New Deal” to reduce inequality. But this one must be bolstered by well-funded and tested social welfare programs designed to improve health.