Rich, poor, healthy, sick

Take two people, one with a college degree and earning $100,000 a year and the other with a high school diploma earning $15,000, and guess which one is likely to have better health.

Those who study population health have long known that, elitist as it sounds, income and education are two of the strongest predictors of overall health in the United States. Americans who are educated and financially secure tend to live longer. They’re more likely to be physically active and less likely to use tobacco. Often they have better health outcomes and better management of chronic conditions such as diabetes or high blood pressure.

Exactly why this would be the case is not clearly understood. One assumption is that it’s all about access – people with more money are able to afford better food, live in safe neighborhoods and receive adequate medical care. Another assumption is that it has to do with healthy or unhealthy community environments. But an interesting review from a few years back indicates it’s much more complex than this.

The authors identify some influences that are familiar. Having more money, for example, means that people have the resources to join a health club or buy fresh fruits and vegetables. Where people live can shape how they behave – whether they have access to parks and sidewalks or the amount of tobacco and fast-food advertising they’re exposed to.

But the authors also identify several factors that are psychological, social and more subtle to tease out.

Education and efficacy. One of the functions of education is to teach critical thinking, problem-solving and self-discipline, which can better equip people to process health information and apply it to their lives. These skills can also make them feel more confident about their ability to successfully manage their health.

- Peer group identification. People tend to associate with their own socioeconomic group and usually will adopt similar norms that reinforce their place in the social ecosystem. If everyone else in your educated, professional social circle is a nonsmoker, chances are you won’t smoke either, or will make serious attempts to quit. Likewise, blue-collar individuals may smoke to show independence, toughness and solidarity with their social group.

- Optimism about the future. Lower lifetime earnings and a sense of limited opportunity can make lower-income people feel there’s less reason to invest in their long-term health. Their health decisions can be more focused on the here and now than on the future. The authors of the review also suggest that the higher levels of stress associated with being economically disadvantaged can lead people to use tobacco, alcohol and/or eating as a way of coping.

Who remembers seeing the headlines this past month about a study that found a link between saving for retirement and being in better health? The researchers may have been onto something, namely that planning for one’s retirement could be just one of many markers for the psychosocial factors that influence health – disposable income, self-efficacy, peer group norms, belief in the future and so on.

Money does indeed make a difference but it isn’t just about money, the authors explain in their review. Walking as a form of exercise costs nothing, while smoking can be an expensive habit. What motivates someone to choose one over the other?

This is only scratching the surface, of course. Many of these factors are interrelated – for example, someone at a lower socioeconomic level who is motivated to adopt healthy habits but has difficulty achieving this because of a lack of means. And it’s hard to outsmart your genetic background regardless of your income or education level or motivation to pursue a healthy lifestyle.

There’s a huge national conversation taking place about being healthy: what it is, how to achieve it and how to reduce some of the obvious income and racial disparities. Do we just keep urging everyone to “make better choices”? Do we legislate? It’s clear from all the research that the social and psychological factors surrounding health-related behavior are complex and not easy to untangle. If ever there was an area to resist simplistic solutions, this is it.

3 thoughts on “Rich, poor, healthy, sick

  1. I believe this article omits one very important factor in why the “haves” are healthier than the “have nots,” and this is: the “haves” generally have health insurance, because they can afford it the premiums and co-pays. Someone working for $8 at Hardees can’t afford health insurance, and probably cannot manage co-pays, etc., and so is more likely to be less healthy, given that all the other variables were the same (health habits, etc.) I used to have a job that had good insurance, though I still rationed out my health care consumption because I had to pay whatever was left over after insurance paid. Thanks to ACA, there are many, many more people with health insurance, though there still may be those who do like I did, and don’t go as often and have things that should be checked out but don’t, because they can’t eke out the cost from their paychecks after all the other bills are paid. So yes, people with money are bound to be more healthy, and a lot of it boils down to being able to afford it.

  2. I agree with the comments by Carlene Dean. In addition, I watched 60 minutes and they had a piece on people living longer – those over 90 and their lifestyles. I couldn’t help but think the piece missed what Anne pointed out and that is the economic impact on health. Until we recognize and enforce education and health care as the key foundation to living a life of quality, we will always have serious gaps between the haves and have nots.

  3. I think being able to afford health insurance does make a difference, but having access to coverage doesn’t automatically make people healthier. There are still all the social and environmental factors to consider – where people live, how they eat, who they hang out with, what they do on a day-to-day basis, etc. What happens in the doctor’s office is only one piece of it, as anyone trying to manage a chronic condition will quickly find out.

    I tend to view health insurance as one of the markers for income and education rather than the final answer. Making it easier and more affordable for everyone to get covered obviously is one of the ways to reduce some of the disparities, but my sense is it will take more than this to really level the playing field in a meaningful way.

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