The HEALTH and WEALTH Connection

We hear a lot these days about the strength of our economy. Wall Street is thriving, and unemployment is at an all-time low. But there is so much more to the story. While people are working and the economy continues to churn out advantages for a small, privileged segment of the population, the realty for the middle and lower classes is devastating. Here are just a few of the sobering statistics:

• 78% of full-time workers live paycheck to paycheck
• 78% of workers say they are burned out at work
• 40% of adults cannot cover a $400 emergency expense
• Nearly 70% of workers say they are in debt
• 40 million Americans are currently living in poverty - the highest income inequality in the Western world

For so many people, if a car or a dish washer or a stove needs repair, they will have to decide between going without or cutting back on food or medicine or…

Take just a minute to cogitate on the last bullet. The poverty level for a household of four is an annual income of $25,750. I am guessing that most people reading this will likely be making far more than that – and perhaps still struggling. Just imagine how you would get by with this full-time income and a family of four!

Wealth Disparity

As bad as income inequality is in our country, wealth disparity is worse, and the gap between the rich and the poor is steadily growing. These two graphics begin to paint the devastating picture. In the United States:

The wealthiest 20 people own more wealth than half of the entire population

The 400 richest people own as much wealth as the entire African-American population plus one-third of the Hispanic population

 Stated a little differently, for the U.S. population as a whole:

• The richest 1% own 40% of the wealth
• The richest 10% own 75.4% of the wealth
• The bottom 90% own 24.6% of the wealth

And the divide is getting progressively worse:

• In 1975 the top 1/10th of 1% of the population owned 7% of the wealth
• In 2000 that increased to 15% of the wealth
• In 2017 that increased again to greater than 20%

And the situation has been deteriorating for decades. As the graph depicts, over the past 30 years, the top 1% of Americans gained $21 trillion in wealth while the bottom 50% lost $900 billion. This means that the top 1% now own nearly $30 trillion worth of assets while the bottom half owns less than nothing, meaning they have more debts than they have assets.

Here is an even more alarming way of visualizing these inequities. Take a moment to think about what it would be like if U.S land was divided like U.S. wealth: 

Given about 325 million people alive today in the United States, this would put more than 290 million of them in the small space below the line running from sea to shining sea. By any stretch of the imagination, that would be an impending disaster!

Regardless of your political persuasion, the critical conclusion here is that this growing wealth gap is simply not sustainable. In fact, history is littered with examples of the devastating consequences wrought by such high levels of wealth inequality. More often than not, the solution only comes about as a result of plagues, revolution, mass warfare or state collapse. 

Healthcare Costs

While the roots of these inequities are many, healthcare costs are certainly a major culprit. We know that the cost of healthcare in our country is out of control. The United States spends twice as much per capita on health care as any other industrialized nation. And we have worse health outcomes even though our utilization is similar. As respected American physician and author Norton Hadler puts it:

“The per capita expenditure of every other resource advantaged country is half that of the U.S. or less without disadvantaging their patients by even an iota. In the U.S. the “system” and its myriad stakeholders are no longer the infrastructure: they are the raison d’etre.”

This should be a major concern for everyone. Resources are finite, and the money must come from somewhere. As the graph shows, the more we increase spending on healthcare, the less money there is available for food, clothing, housing and other necessities of life.

And exacerbating the situation, average insurance deductibles have increased 8 times as fast as wages.

We know that for the 40 million Americans living in poverty, this means that a family of four must get by on less than $26,000 per year. As the graph from the KFF Employer Health Benefits Survey 2018 shows, the average worker is paying around $7,000 per year for health insurance (or close to $20,000 for family coverage). It is no wonder that people’s lives are being thrown into chaos.

The damage this is causing is hard to overestimate. The graph below shows what happened in the state of Massachusetts between 2001 and 2014. Increases in healthcare spending led to devastating decreases in the resources available for public health, mental health, infrastructure (housing and economic development), education, human services, local aid, and law and public safety. And people’s health suffers as they are constantly having to make decisions about whether to pay for food or medicine.

And what about the epidemics of suicide and drug overdoses we are experiencing? These are frightening statistics for sure:

• Drug overdose deaths exceeded 70,000 in 2017, nearly 6,600 more than in 2016.
• The rate has increased on average by 16 percent per year since 2014 and more than tripled since 1999.
•  In 2017, 47,000 people committed suicide, a rate of 14 per 100,000 people.
• The total number of suicide deaths was the highest in a half-century and up more than 2,000 from 2016.
• In 2017, suicide and drug overdose rates together reached the highest total in more than 100 years.

What is the connection between these sobering statistics and our economic woes? William Dietz, a disease prevention expert at George Washington University connected the dots:

“Financial struggles, a widening income gap and divisive politics cast a pall over many Americans. I really do believe that people are increasingly hopeless, and that leads to drug use, it leads potentially to suicide.”

All of this is depressing as hell. There is some good news however, at least in terms of healthcare costs. The good news is that we now know what to do to substantially lower healthcare costs, particularly for organizations and their employees. Health Rosetta is a nonprofit organization pushing back against 50+ years of hyper-inflating healthcare costs. They are a collective group of experts who have “cracked the code” to the healthcare crisis and are on a mission to scale it through employers and building a health ecosystem. The motto on their website says it all.

"Healthcare is already fixed - Join us to replicate the fixes."

They have helped and are continuing to help numerous public and private employers and unions provide better care while reducing health benefits spending by 20-40 percent. Really!

Health Disparities

The solutions to our health and wealth disparities are far more complex. There has been a tremendous amount of discussion recently about the sorry state of health in our country. We are constantly being warned that we are in the midst of a number of devastating epidemics (obesity, diabetes, etc.) and that as a result, our children are not going to live as long as their parents. Regularly scolded by prevention experts, health professionals and just about anyone else who has a computer and an internet hookup, we are told (often in quite demeaning terms) that we are simply too fat, too sedentary and eating all the wrong foods.

U.S. life expectancy is indeed stagnating. But perhaps ironically, it is not about obesity or what we are eating or how many times we go to the gym, but rather about intense desperation and isolation, driven by economic uncertainty and deprivation and exacerbated by the ever-increasing cost of healthcare.

The solution according to the experts has traditionally been that if we would just exercise and eat the way they say we should, it would fix our broken health care system, prevent 80-90% of chronic diseases and maybe even save the planet.

For example, we often hear people say, “you are what you eat,” insinuating that what you eat is the major determinant of how healthy you are or how long you will live. While nutritional intake can impact health, for countries like ours, it is neither the major determinant of longevity, nor the major cause of poor health.

If we really want to uncover the major causes of poor health, we simply must look beyond individual health behaviors. This is especially true in countries like the United States where most people (though not all) have enough to eat. In countries where this is not the case, food (more accurately not having enough food) can play a much larger role in health outcomes. But in what are often referred to as “first world nations” like ours, disparities in health are most powerfully impacted by other factors.

The Social Determinants of Health

This graphic from the Centers for Disease Control below represents decades of work on this topic. Though individual health behaviors like nutrition are important, their impact on health disparities pales in comparison to what are often referred to as the Social Determinants of Health (SDOH).

We see that all individual health behaviors combined account for about 25% of the disparities in health across our population. And our nutritional intake is only one component of those behaviors! If we look a bit more closely at these social determinants, what we find is that they have to do with, as Dr. Michael Marmot, perhaps the world’s leading expert on SDOH summarizes:

“Conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”

The impact of these conditions is profound. As just one powerful example, in his seminal 2004 book, The Status Syndrome: How Social Standing Affects our Health and Longevity, Dr. Marmot reports that if you travel the 12 miles from downtown Washington DC to the suburbs of Maryland, life expectancy increases about 20 years!

The bottom line is YOU ARE WHERE YOU LIVE is likely a more accurate appraisal of your health and wellbeing than YOU ARE WHAT YOU EAT! Clearly, the major causes of our health problems are inextricably linked to the devastating consequences of the disparities in wealth we have been discussing. In fact, according to the Centers for Disease Control and Prevention, “your zip code can be more important than your genetic code.”

And in terms of the opioid epidemic that is wreaking havoc throughout our nation, Health Rosetta founder Dave Chase in his powerful 2017 book, The CEO’s Guide to Restoring the American Dream: How to Deliver World Class Healthcare to Your Employees at Half The Cost, identifies a very similar predicament when he identifies the ultimate solution:

“A community that addresses social determinants of health like safe neighborhoods, quality jobs, and a health care system that can treat those afflicted with opioid overuse disorders while preventing others from being drawn into the hell of addiction.”

What Can be Done?

The solutions to the existential predicament in which we find ourselves are difficult and complex, and an in-depth exploration of them is beyond the scope of this piece. Preventing the devastating consequences of the growing wealth disparities in our nation will take a concerted effort from all parts of society.

The solutions will necessitate an intensive focus on Health Equity as defined by Professor of Family and Community Medicine and Director of the Center on Social Disparities in Health at the University of California, San Francisco Paula Braveman:

“Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

Though the United States lags behind other first world nations in recognizing and addressing these issues, and our political system seems to be impotent at best, progress is being made on a number of fronts. Albeit belatedly, our medical establishment is at last recognizing the critical importance of the SDOH.

• By beginning to include SDOH issues in their assessments and treatments
• With urgent calls for including SDOH in graduate medical education
• Helping Medicaid participants with SDOH concerns
• With some hospital systems doing the same
• As part of the Healthy People 2020 initiative, The Office of Disease and Health Promotion, part of the U.S. Department of Health and Human Services is now stressing the critical importance of addressing the SDOH

And the business world is stepping up as well. The obsessive focus on individual health behaviors that has dominated the workplace wellness landscape since the passage of the now discredited Safeway Amendment in the Affordable Care Act of 2010 is giving way to the understanding that the health and wellbeing of employees is tied directly to the culture of the organization. What is needed are leaders who create the conditions for physical and psychologically safety at work, so employees feel engaged and fulfilled in an atmosphere that encourages them to take risks and innovate.

The Conscious Capitalism movement is leading the way in this regard by seeking to change the way business is done, moving away from a primary focus on shareholders to approaches that honor all stakeholders equally with a critical focus on the SDOH, as their credo clearly articulates.         

“We believe that business is good because it creates value, it is ethical because it is based on voluntary exchange, it is noble because it can elevate our existence and it is heroic because it lifts people out of poverty and creates prosperity. Free enterprise capitalism is the most powerful system for social cooperation and human progress ever conceived. It is one of the most compelling ideas we humans have ever had. But we can aspire to even more.”

Finally, some enlightened companies are attacking the injustices of income and wealth disparity head on. The practice of paying workers biweekly is a throwback to the days when it took considerable time to get a payroll processed. Today’s technology makes this practice obsolete and its persistence creates a huge unnecessary source of financial duress for the more than 90 million people living from paycheck to paycheck. In essence, it really amounts to the employer unnecessarily using employees money as a source of zero interest credit!

PayActiv is a company created by Silicon Valley entrepreneur Safwan Shah that helps businesses of all sizes establish systems which allow employees to access their earnings when they need them as opposed to having to wait till the next pay period. You can learn more about how to bring this to your organization here or from reading Safwan’s fascinating book It’s About Time: How Business Can Save The World (one worker at a time).

Aside from helping to alleviate some of the financial stress we have been discussing here, innovations such as this can improve employee morale and engagement and positively impact a company’s bottom line by reducing absenteeism, improving productivity and increasing retention. A win-win situation for all concerned!

Innovations such as these, that focus on equity and social justice are the best and perhaps the only way to overcome the health and wealth disparities that have created these existential threats to our great nation. It will take the combined efforts of diverse sectors of our society, but at the end of the day, it is likely business that will lead the way. As Dr. Raj Sisodia, co-founder of Conscious Capitalism explains:

“People are broken, burned out and stressed out. The human cost of doing business has become unacceptably high…If we do it right, business can actually alleviate suffering and bring joy into people’s lives.”

To most effectively impact the health of all Americans, we simply have to address the growing wealth chasm we are facing. We have the data and the resources to make this happen. Now all we need is the will!

Thanks and take care - Dr. Jon