The American Dream? Investigating Health Care in the U.S.

In every corner of the world, the rich live longer than the poor. This is equally true in the United States. In mid-December, the Associated Press (AP) analyzed life expectancy collected by the National Center for Health Statistics by census tract. The 65,662 census tracts are geographic areas in which about 4,000 people live. The AP found that high unemployment rates, low rates of graduation from high school, low household incomes, and higher percentages of black or Native American residents were all associated with lower life expectancy. While life expectancy varied by state (Hawaii had the highest at 82 years; Mississippi had the lowest at 74.9), the national average was 78.6 years, and in-state variations were far more dramatic than national-level variations. For example, in New York, children born in the northern half of Roosevelt Island between 2010 and 2015 had an estimated life expectancy of 59 years, while those born in Chinatown, located in lower Manhattan (six miles away), were expected to live 93.6 years! In Massachusetts, a generally wealthy and well-educated state, the average life expectancy is 80.7 years, but within the state, there are huge variations. In the census tract with the lowest life expectancy, 45 percent of the inhabitants did not finish high school and 13 percent were unemployed; the people were evenly split between Hispanics and non-Hispanic whites. By contrast, in the neighborhood with the highest life expectancy, only one percent did not finish high school, 2.7 percent were unemployed, and the population were mostly white. Why is this?

To be healthy, it is clearly advantageous to have adequate access to medical care. People need to have doctors and hospitals available, get immunizations, get appropriate screening tests, and be able to afford their prescribed medications. They also need to have access to good food and housing and have good health habits, including exercise, and abstention from smoking, alcohol, and drugs.

But health disparities in the United States are many and varied. A study published in JAMA Network Open in November 2018 found that people who suffered cardiac arrests in the poorest neighborhoods around the country had longer delays in getting emergency care than did similar patients in richer neighborhoods. Maternal morbidity, which I discussed in a prior blog, disproportionally affects poorer black women. A study published in Obstetrics and Gynecology found that severe morbidity occurred almost twice as often in black mothers than in non-Hispanic white mothers. The Journal of the American Heart Association published a study online last month showing that living in a neighborhood with lots of trees and other greenery improves many markers of cardiovascular health. And, of course, it’s not just greenery but “greens” that are important. People living in “food deserts,” as I describe in “Prescription for Bankruptcy,” have a higher burden of cardiovascular risk factors, and are much more likely to be readmitted to hospital after being treated for congestive heart failure.

In November, social media was abuzz when a 60-year-old woman was denied listing for a needed heart transplant because of her finances and was advised to start a fundraising effort. After she raised more than $30,000 via GoFundMe, she was added to the transplant waiting list. Hospital officials defended their behavior, which is very common at all transplant centers, by noting that patients must be able to afford expensive medications after transplant to prevent rejection (wasting a very limited resource).

Among the many diseases that disproportionately affect the poor, cancer may be the cruelest. The poor are less likely to get early screening and more likely to delay seeking care because of cost concerns. Cancer treatment often renders the patients unable to work, a huge problem for those with limited resources on which to fall back. Gallup’s annual “Health and Health Care” poll last year found that 29 percent of Americans held off seeking medical care because of financial concerns, and 19 percent said the delay involved a serious condition. Not surprisingly, this behavior varied by income. Twenty-two percent of those who delayed medical care because of cost had a family income of $75,000 or more; 34 percent had a family income of $30,000–74,999; and 38 percent had an income less than $30,000.

We need to bring the cost of health care in the United States closer to the costs in other Western democracies. While the U.S. spend roughly twice as much per capita on health care as do comparable European countries, we spend less on social services — elder home service, paid maternity leave, housing, and early child care. If we were to modestly increase funding for these services, we could lower our health care spending by more than the added expenditure.


Dr. Hoffer graduated from the Massachusetts Institute of Technology and Harvard Medical School. He recently closed his private Cardiology/Internal Medicine practice but continues to work at the Massachusetts General Hospital on decision support. He recently published a book, “Prescription for Bankruptcy,” on the failing American health care system.

Image by retrorocket / Shutterstock

More from Op-Med