Series

America: Equity and Equality in Health 1

Inequality and the health-care system in the USA
Samuel L Dickman, David U Himmelstein, Steffie Woolhandler

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. Lancet 2017; 389: 1431–41
The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a See Editorial page 1369
Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based See Comment pages 1376
disparities in health, instead often exacerbates them. Other articles in this Series address population health and 1378
inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans This is the first in a Series of
have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage five papers about equity and
equality in health in the USA
expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have
Department of Medicine,
undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health- University of California,
care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, San Francisco, CA, USA
from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of (S L Dickman MD); City
medical care borne by non-wealthy Americans. University of New York School
of Urban Public Health at
Hunter College, New York, NY,
Introduction research by the economists Piketty and Saez5 that USA (Prof D U Himmelstein MD,
As economic inequality in the USA has deepened, so too revealed levels of income inequality unrivalled since the Prof S Woolhandler MD); and
has inequality in health. Almost every chronic condition, stock market bubble of the 1920s. The share of total Harvard Medical School,
Boston, MA, USA
from stroke to heart disease and arthritis, follows a income going to the top 1% of earners has more than (Prof D U Himmelstein,
predictable pattern of rising prevalence with declining doubled since 1970 (figure 1),6 while most workers in the Prof S Woolhandler)
income.1 The life expectancy gap between rich and poor USA have experienced slow income growth.7 As Correspondence to:
Americans has been widening since the 1970s,2 with the measured by the Gini coefficient, a standard metric of Prof David U Himmelstein, City
difference between the richest and poorest 1% now income inequality, the USA is now more unequal than all University of New York School of
Urban Public Health at Hunter
standing at 10·1 years for women and 14·6 years for but three other countries (Chile, Mexico, and Turkey) in College, NY 10035, USA
men.3 The health of poor communities is often neglected: the Organization for Economic Co-operation and dhimmels@hunter.cuny.edu
for example, in Flint (MI, USA), a de-industrialised, Development (OECD). The most equal countries are See Online for infographic
impoverished, and predominately African-American city, Denmark, Slovenia, Norway, and Slovakia. www.thelancet.com/
public officials dismissed evidence that children were The surge in top incomes has magnified inequality in infographics/us-health

being exposed to toxic levels of lead in the city’s drinking
water for several months.4
Attention to economic inequality intensified after the
Occupy Wall Street movement decried the rising wealth
and power of the richest 1%. This movement popularised
Search strategy and selection criteria
We searched PubMed and Google Scholar using the following
terms: “health care quality” OR “quality of care” AND “primary
care” OR “specialty care” OR “specialist” OR “hospital” OR
“surgery” OR “cancer” OR “outpatient” AND “inequality” OR
“unequal” OR “disparities” AND “US” OR “United States”;
“access to care” OR “health care access” OR “barriers to care”
AND “inequality” OR “unequal” OR “disparities” AND “poor”
OR “poverty” OR “wealthy” OR “income” AND “US” OR
“United States”; “regressive” OR “progressive” AND “health
financing” OR “health finance” OR “out of pocket”; and
“medical bankruptcy” OR “medical debt”. Our search included
articles focusing on the USA published in English between
Jan 1, 2011, and March 31, 2016, prioritising recent research.
We identified additional sources, including important older
manuscripts, from the reference lists of selected articles and
from consultation with expert colleagues.
wealth (ie, assets). Since 1986, the top 0·1% of households
(those with assets exceeding US$20 million) has
Key messages
• Economic inequality in the USA has been increasing for decades and is now among the
highest in developed countries.
• Differences in life expectancy have been widening, with the wealthiest Americans now
living 10–15 years longer than the poorest.
• Despite coverage gains from the Affordable Care Act, about 27 million Americans
remain uninsured—a number that is likely to increase under the reforms advocated by
Republicans now empowered in Washington, DC.
• Both overall and government health spending are higher in the USA than in other
countries, yet inadequate insurance coverage, high cost sharing by patients, and
geographical barriers restrict access to care for many.
• Financing of health care in the USA is regressive, with poor and middle-class
individuals paying a larger share of their incomes for care than the affluent, thereby
deepening inequalities in disposable income.
• Rising insurance premiums for employer-sponsored private coverage have eroded
wage gains for middle-class Americans.
• Medical indebtedness is common among both insured and uninsured Americans, and
often leads to bankruptcy.
• To achieve health-care equality, a non-market financing scheme that treats health care
as a human right is essential.

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20 middle-class families have been bankrupted by illness

and medical bills.14 Meanwhile, very wealthy Americans
are turning to so-called concierge practices that offer
lengthy office visits and unfettered access to specialists.
This Series paper examines how the health-care system
Share of total income (%)

15
in the USA contributes and responds to inequality. We
focus our attention on the association between inequality
and the medical care system.
We first review how social position influences
10 Americans’ access to medical services and the quality of
those services. The uninsured face the greatest barriers
to care, but many insured Americans are also unable to
afford medical care because of cost sharing. Although
race-based disparities in quality are well documented, the
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low quality scores of doctors and hospitals serving poor
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Figure 1: Share of total income received by the top 1% of earners in the USA, 1913 to 2014
Source: Saez (2016).6 Income is defined as pre-tax market income excluding capital gains and government
transfers. In 2014, the top 1% included families with annual incomes above $387 810, who collectively received
18% of total income in the USA.
accumulated nearly half of all new wealth, and now
controls as much wealth as the bottom 90%, whose share
has fallen steadily.8
Wealth inequality between racial and ethnic groups in
the USA is especially striking, and is several times
greater than income inequality. In 2013, median family
wealth for the non-Hispanic white population was ten
times that of Hispanics and more than 12 times that of
African-Americans.9 The racial wealth gap results from
historical factors dating back to slavery—many of which
persist—including legalised racial segregation in the pre-
civil rights era, pervasive job and housing discrimination,
exclusionary city zoning laws, unequal education, and
inheritance laws that perpetuate past inequalities.10
Although top incomes have risen, so has extreme
poverty. More than 1·6 million households in the USA,
including 3·5 million children, survive on incomes of
less than $2 per person per day—WHO’s definition of
extreme poverty; this number has more than doubled
since the 1990s.11
The health-care system could soften the effects of
economic inequality by delivering high-quality care to all.
Yet the institutions and financing patterns of the health-
care system in the USA—by far the world’s most
expensive12–cause it to fall short of this ideal. Although
inequalities exist to some extent in every health-care
system, they are particularly stark in the USA. Unequal
access to medical services is likely to contribute to
disparities in health status, while rising costs (for both
the insured and uninsured) reduce disposable incomes,
particularly burdening low-income households.
Many patients cannot afford the care they need, and
often forgo medical care altogether. For example, 19% of
non-elderly adults in the USA who received prescriptions
in 2014 (after full implementation of the Affordable Care
Act [ACA]) could not afford to fill them.13 Millions of
circumstances rather than their providers’ performance.
We also review how the health-care costs borne by
households—in the form of insurance premiums, taxes,
and out-of-pocket payments—exacerbate income
inequality, forcing many Americans to cut back on food
and other necessities, and contributing to most personal
bankruptcies. We conclude by discussing the historical
context for today’s health-care inequalities, and propose
options for reform.
Inequality and access to care
Income-related disparities in access to care are far wider
in the USA than in other wealthy countries.15 Before the
2010 passage of the ACA, which progressively expanded
health insurance coverage, 39% of Americans with
below-average income reported not seeing a doctor for a
medical problem because of cost, compared with 7% of
low-income Canadians and 1% of those in the UK.16
Inequality in access to care is particularly stark in
Southern states. For example, in Texas, Mississippi, and
Florida, adults on a low income are more than twice as
likely to face cost-related barriers to care as their
counterparts in Maine (a relatively poor New England
state) and Massachusetts.17
Disparities in access are largely due to high rates of
uninsurance or inadequate health insurance among low-
income Americans, although Americans with above-
average incomes probably also have worse access to care
than do their peers in other countries.16 Today, despite gains
due to the ACA, 27 million Americans (down from
50 million before the passage of the ACA) remain
uninsured. Most of the uninsured have annual incomes
near or below the official poverty line ($11 770 for an
individual in 2016).
The uninsured are far more likely than the insured to
forgo needed medical visits, tests, treatments, and
medications because of cost. Cost barriers are especially
severe for the millions of uninsured Americans with
chronic conditions.18 For example, middle-aged adults
with no coverage for eye care report difficulties in
reading or recognising a friend across the street

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more frequently than do comparable individuals with
coverage.19 Uninsured individuals with diabetes spend,
on average, $1446 out of pocket for medical services
each year, and more than 30% do not have a primary
care provider.20 Similarly, low-income and uninsured
Americans with psychiatric disorders are far more likely
than the insured and those on higher incomes are to
experience difficulties obtaining care.21 For poor
Americans, gaining insurance boosts access to care
(although it does not fully close the gap between poor
and affluent patients), leading to more visits for
preventive screenings and greater satisfaction with care
than before gaining coverage.22
Medicaid insurance for low-income Americans
Medicaid, the public insurance programme that covers
58 million low-income Americans, improves health
outcomes and access to care for its beneficiaries.23
Gaining Medicaid coverage reduces rates of clinical
depression,24 financial problems due to illness,24 and
mortality.23 The generosity of the Medicaid programme,
which is largely controlled by state governments, is a
key determinant of access-related disparities. Before
the passage of the ACA, most states restricted Medicaid
eligibility to poor children and pregnant women,
disabled people, and the poorest adults with children.
Childless adults and parents with incomes above
stringent state-specific thresholds (eg, 10% of the
poverty level in Alabama) were generally excluded.
The ACA’s expansion of Medicaid to all citizens with
annual incomes at or below 138% ($16 643 for an
individual in 2017) of the poverty level promised to
cover millions of previously uninsured Americans.
However, the US Supreme Court ruled in 2012 that
states could opt out of the Medicaid expansion, and the
Trump administration is likely to further erode or
repeal it. As of 2016, 19 states (mostly in the South)
have opted out, cutting the number of citizens who
would otherwise have gained coverage by about
5 million. An additional 5–6 million undocumented
immigrants do not have insurance because the
ACA specifically excluded them from its coverage
expansion,25 perpetuating major constraints on their
access to care.26 Fortunately, the ACA increased funding
for community health centres, which deliver much-
needed care to millions of low-income Americans, and
extended mental health parity regulations aimed at
improving insurance coverage for mental health and
addiction treatment.
Although Medicaid improves access to care, specialist
care is often unobtainable because the programme pays
low fees to physicians,27 who are free to turn away
Medicaid patients. For example, 76% of orthopaedists’
offices in a nationwide audit study refused to offer an
appointment to a Medicaid-insured child with a
fracture, whereas only 18% refused a child with private
insurance.28
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Cost sharing and private insurance
In the private insurance market, cost sharing by patients
(ie, through user fees) has increased substantially since
the 2000s.29 Many plans now impose co-payments of
more than $30 for primary care and more than $45 for
specialist visits.30 More than 80% of employer-based
plans include an annual deductible (the amount a patient
must pay before insurance covers additional costs),
which averaged $1478 in 2016, an increase of 2·5 times
since 2006.30 Cost sharing by patients is even higher in
plans sold through the insurance exchanges created by
the ACA. In mid-level, so-called silver tier plans (which
account for about 70% of exchange coverage), deductibles
averaged $3064 in 2016,30 although some subsidies were
available to cushion the deductibles for enrollees with
incomes 100–250% of the poverty level.
Many private plans also reduce premium costs by
restricting patients’ choice of providers to narrow
networks of doctors and hospitals, which often exclude
academic and cancer referral centres.31 Enrollees who
seek out-of-network care (either by choice or because of
medical necessity) generally must pay the entire bill out
of pocket.
Predictably, patients’ use of care declines as their cost-
sharing obligation rises, and people with the worst health
are most likely to cut back on care.32 Paradoxically, this
reduction in care-seeking can fail to cut system-wide use,
instead shifting care from the sick and poor to the healthy
and wealthy. At least in some cases, when poor patients
avoid care, doctors and hospitals fill the empty
appointment slots and beds with patients who are less
price-sensitive33—an example of supply-sensitive
demand.34 Strikingly, the USA has the world’s highest
health-care expenditures despite extensive cost sharing
by patients.
Additionally, care forgone because of cost sharing
might ultimately raise costs by increasing downstream
health problems. When the Medicare programme (the
public coverage for people aged 65 or older and those
with long-term-disabilities) added new co-payments,
outpatient visits decreased but hospital admissions
increased.35 Among patients who developed a
myocardial infarction, elimination of medication co-
payments after the cardiac event increased compliance,
and (for racial and ethnic minority patients) led to a
35% reduction in major vascular events and a
70% reduction in total health-care spending.36 Similarly,
among children aged 5–18 years with asthma, those
whose insurance required higher co-payments used
fewer medications but had a 41% greater risk of asthma-
related hospital admissions than did children with
lower co-payments.37 For nearly a third of children with
asthma from low-income families with high cost-
sharing coverage through the Kaiser Health Plan,
parents reported delaying or avoiding outpatients visits,
and 14·8% reported non-adherence to medications
because of cost; 15·6% of all parents (including those
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with higher incomes) reported borrowing money or
cutting back on necessities to pay for their children’s
asthma care.38
Defining underinsurance
Rising deductibles and other forms of cost sharing by
patients have eroded the traditional definition of
insurance: protection from the financial harms of illness.
The term underinsurance describes this problem, but it
does not have a standard definition. Some studies of
underinsurance have focused on financial vulnerability
(eg, measurement of deductibles as a fraction of
income),39 others on out-of-pocket costs incurred (either
in absolute dollars or relative to income),40 whereas
others have highlighted barriers to care (because of cost
or narrow insurance networks).41 No standard quantitative
thresholds exist for these different concepts.
The various definitions of underinsurance highlight
two related but distinct problems: people with inadequate
insurance risk financial harm when they receive medical
services, and they are therefore less likely to obtain
needed care. Despite the absence of consensus on the
definition of underinsurance, it is clear that these
problems affect many Americans with private coverage
and have increased.
Between 2004 and 2013, high rates of uninsurance,
rising cost sharing (ie, underinsurance), and stagnant
incomes all contributed to a decline in overall health-
care consumption (as measured by the total amount
spent by insurers and patients) for poor Americans, a
trend that was reversed in 2014 when the major
provisions of the ACA came into effect (figure 2).42 For
the first time since the 1970s, per-capita medical
expenditures for the poorest fifth of Americans (who
are, on average, much sicker than the wealthiest 20%)
6000 Poorest quintile
Middle 60%
Richest quintile
5000
Health expenditure per capita (US$)
dipped below those of the wealthiest 20%.42 In Canada,
by contrast, the poorest citizens receive the most
medical services, commensurate with their increased
health needs.45 Meanwhile, health-care expenditures for
the wealthiest 20% of Americans accelerated, raising
their share of overall health-care consumption. The
ACA, fully implemented in 2014, led to a surge in
health-care expenditures for the bottom 20%, but
expenditures for the middle class have flattened while
health-care consumption by the wealthiest Americans
continues to grow.
Access problems
Geography often affects access to care. Because
physicians are concentrated in cities and affluent
suburbs, many Americans living in rural areas find it
difficult to obtain primary46 and specialty care.47 Many
rural and Southern states also have a shortage of adequate
family planning resources. Texas, for example, has
imposed onerous regulations and funding cuts on family
planning clinics, causing closure of many48 and a
subsequent increase in unwanted pregnancies.49 Since
the closure of the last local abortion clinic in 2013,
women in Lubbock, Texas (population 244 000), are now
more than 250 miles away from the nearest abortion
provider.
Women are also at a financial disadvantage because of
their greater health-care needs (including reproductive
care) than those of men. Although fewer women than
men are uninsured, those with insurance have higher
out-of-pocket costs. For example, among people with
employer-sponsored coverage, women’s out-of-pocket
costs were $233 higher than men’s in 2013;50 among
Medicare enrollees, such costs were $640 higher for
women than they were for men in 2011.51 These costs are
especially burdensome because women’s median
incomes are 39% lower than those of men.52
Illness-based disparities are particularly stark for
mental illness and substance abuse. Historically, a large
share of psychiatric care was paid for out of pocket or

provided in underfunded public institutions. Jails

4000 remain the largest so-called inpatient mental health
facilities in the USA. Although the 2008 Mental Health
3000
Parity and Addiction Equity Act mandated that
most insurance plans provide equivalent coverage for
mental and physical illness, implementation of
2000
this requirement was delayed until 2015, and its
enforcement has proven difficult.53 Moreover, most
1000 Medicaid programmes (which cover many people with
mental disorders) are exempt from these regulations.
0 Psychiatric—and particularly substance abuse—
providers are in short supply on a national scale,
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been particularly hard hit by the epidemic of drug
Figure 2: US health expenditures per capita, adjusted for inflation, by income group, 1963 to 2014
Sources: Dickman and colleagues (2016);42 and the Medical Expenditures Panel Survey43,44 (for years 2013–14). overdoses and self harm, which pushed up the overall
Figures for 1996 to 2013 are 2-year moving averages; single-year figures are provided for 2014 to show the effect death rate in the USA in 2015. The ACA, which applied
of the Affordable Care Act’s coverage expansions in this year. the parity requirement to the plans sold through the

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exchanges, increased access to mental health, but not to
substance abuse treatment; substantial racial and
ethnic disparities persist.54
Inequality and quality of care
For many conditions, increased quality is implied by, and
inseparable from, improved access to care. An increased
frequency of primary care visits, for example, is
associated with improved control of diabetes.55 Similarly,
among patients who developed an acute myocardial
infarction, the uninsured were 38% more likely (and the
underinsured 21% more likely) than the well insured to
delay seeking emergency care.56
Yet it is unclear whether income-related disparities in
access to care are accompanied by other gaps in global
quality, which are harder to measure. Poverty itself
causes ill health, compromises non-medical social
supports and resources that improve medical outcomes,
and is associated with worse satisfaction with care.57
Hence, differences in the socioeconomic profile of
patients, rather than true differences in quality of care,
might explain why hospitals58 and physicians59 caring for
poor patients score lower on some quality metrics than
do health-care providers serving affluent areas.
Assessment of quality differences is increasingly
difficult because tying quality indicators to financial
incentives can induce so-called gaming, which distorts
measurement.60 Nonetheless, payers have implemented
pay-for-performance schemes that reward providers on
the basis of proxy measures of quality, and facilities
serving poor patients have been disproportionately
penalised. For example, safety-net hospitals have seen
their payments reduced under Medicare’s Hospital
Readmission Reductions,61 Hospital-Acquired Condition
Reduction,62 and Hospital Value-Based Purchasing
programmes.63 Disturbingly, such programmes introduce
perverse incentives to avoid poor patients, while shrinking
funding for hospitals and physicians continuing to care
for them.
In view of the pitfalls of quality measurement, what can
be said about the association between social disadvantage
and the quality of medical services? A classic study of
patients admitted to hospital in 1984 found that uninsured
patients were at higher risk (odds ratio 2·35) of receiving
substandard medical care than their insured counterparts.64
However, safety-net hospitals (and hospitals in the
Veterans Administration [VA] system, which serves mostly
non-affluent veterans) have risk-adjusted mortality rates
for older patients similar to those of other hospitals. By
contrast, small hospitals serving isolated rural areas appear
to deliver a lower quality of care for medical conditions
than other hospitals do, as measured by both process-of-
care metrics and mortality.65 Studies of differences in
surgical quality and safety are inconclusive,66 although
risk-adjusted outcomes appear worse for poor patients
across a range of surgical procedures.67 Poor patients are
more likely than affluent patients to receive dangerous
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drugs: 27% of low-income Medicare beneficiaries with
dementia, hip or pelvic fracture, or chronic renal failure
received contraindicated medications compared with 16%
of higher-income individuals.17 Poor Americans older than
50 years are also far less likely than their affluent
counterparts to receive recommended influenza and
pneumonia vaccinations, and cancer screening tests,17
although cost-related barriers might underlie these
differences.
There is strong evidence showing that quality of care is
worse for racial and ethnic minorities,68 although racial
disparities in the quality of hospital care could have
narrowed between 2005 and 2010 as a result of
improvements among hospitals serving patients from
minority backgrounds and more equitable care within all
hospitals.69 Yet unequal access to care, along with
institutional racism, remain important drivers of persistent
disparities in health-care quality for racial and ethnic
minorities. For example, although African-Americans tend
to live closer than white patients to high-quality hospitals,
they are less likely to have their surgeries there.70 The
intersection of race, racism, and the health-care system in
the USA is reviewed elsewhere in this Series.
Health-care financing inequality
The USA finances medical care through a complex
network of public and private insurance programmes, as
well as substantial direct payments by patients. Figure 3
shows the proportion of Americans covered by the main
insurance programmes, and the major sources that fund
health care. Taken together, government insurance
programmes—principally, Medicare, Medicaid, and
military health care—account for 42% of personal health-
care expenditures.72 Yet this figure substantially understates
the government’s share, because it excludes two large, tax-
funded outlays for private insurance: government agencies’
expenditures to purchase private insurance for public-
sector employees (representing 28% of all employer
payments for private coverage) and tax subsidies for private
firms’ purchase of insurance for their employees. Taking
into account these two additional categories boosts the
public share of total health funding in the USA to 65%.73
Total health-care expenditures by the government in the
USA exceed the total public and private spending per head
of any other country except for Switzerland.73 In light of
this fact, the stark inequalities in health care faced by
millions of Americans seem particularly unjust.
The complexity of health-care financing in the USA
obscures not only the magnitude of public funding but
also the regressive pattern of who ultimately pays. In fact,
health care takes a substantially larger share of income
from the poor than from the wealthy, exacerbating
inequalities in disposable income.74 Although com­parative
international studies are scarce and mostly old, financing
schemes in other wealthy countries are generally less
regressive (although cost sharing is rising in some
European countries75). Health-care systems financed
 Series

primarily through income taxes, as in Ireland, the UK, and noted previously, insured patients often bear a heavy
Portugal, tend to be the most progressive, whereas those (and regressive) out-of-pocket burden for deductibles, co-
relying on private insurance and out-of-pocket payments, payments, and out-of-network care. Even older patients,
as in Switzerland and the USA, are more regressive.76 almost all of whom are covered by Medicare, face high
out-of-pocket costs for their share of the premiums, as
The redistributive effect of specific health-care well as co-payments and deductibles,78 a burden that falls
financing programmes most heavily on low-income senior citizens. For Medicare
Direct out-of-pocket spending is the most regressive enrollees, out-of-pocket medical expenses consume
form of health-care financing. The uninsured (who are 11·2% of income among those with incomes above 300%
disproportionately poor) pay for much of their care out of of the poverty level, and between 22·7% and 26·8%
pocket and, because they do not have insurers’ among those with incomes below 200% of the poverty
negotiating leverage, are charged the highest prices.77 As level.51
In an effort to reduce the burden of catastrophic
medical bills, the ACA imposed limits on out-of-pocket
A Insurance enrolment, USA (millions) medical costs in private plans ($6850 per year for
individual plans and $13 700 for families in 2016), Yet
these limits, which do not apply to out-of-network and
so-called non-essential services, vastly exceed most
33·0
14·1
families’ savings.79
Private insurance premiums are also regressive74 and
Employment-based private have risen faster than earnings (figure 4); premiums for
55·9 Direct purchase private
Medicare
employer-based plans increased by approximately three
175·0 Medicaid times between 1999 and 2016.29 The poorest fifth of
Military related Americans spend, on average, 6% of their income on
Uninsured
private insurance premiums, while the wealthiest fifth
50·5
spend just 3·2%.74 Although employers typically make
sizeable contributions to their employees’ premium
46·2
costs, economists believe that this expense is mostly
passed on to employees in the form of lower wages.
Medicaid is the most progressively redistributive health
insurance programme in the USA. It requires little cost
B Payers, USA (US$ billions) sharing by patients, is financed through federal and state
taxes (with progressive income taxes providing the largest
share),81 and most of the benefits go to poor citizens.
Medicare is funded largely through federal general
Private employer payments revenues and a payroll tax, which remains less
$338·1 for private insurance
$646·2 progressive than Medicaid’s funding base (despite the
Household payments for
private Insurance ACA’s extension of the payroll tax to some investment
Household out-of-pocket
$345·3 Medicare income). Medicare covers both affluent and poor senior
Government spending Medicaid citizens, but its high and regressive cost-sharing
$545·1 Other public
Government payments for
requirements discourage many low-income beneficiaries
public employees' private from seeking care.82 Moreover, the growing gap in life
$484·8 $341·9 health insurance and for expectancy between the rich and the poor means that
subsidies for private
coverage under the ACA wealthier Americans will, on average, live to enjoy many
$240·1 more years of publicly funded benefits after becoming
eligible at the age of 65 years.83 As a result, among men
born in 1960, lifetime Medicare outlays are expected to be
28% higher for the wealthiest fifth than for the poorest
Figure 3: Proportion of Americans covered by the main insurance programmes (A) and main sources of fifth, a reversal of the pattern 30 years earlier.83 Similarly,
health-care funding (B) immigrants (especially the undocumented) collectively
(A) Source: US Census Bureau, Current Population Survey, 2015.52 Individuals may have had more than one type of
insurance. “Medicaid” excludes individuals with both Medicare and Medicaid. (B) Source: National Health contribute billions more in taxes to Medicare each year
Expenditure Accounts, US Centers for Medicare & Medicaid Services, 2015.71 The government spending figure than they receive in benefits.84
excludes $326·2 billion in tax subsidies. “Other public” includes maternal and child health, vocational rehabilitation,
the Substance Abuse and Mental Health Services Administration, the Indian Health Service, federal workers’
compensation, other federal programmes, public health activities, the US Department of Defense, the US
Medical bills and financial hardship
Department of Veterans Affairs, the Children’s Health Insurance Program (CHIP), as well as investment programmes The health-care financing system in the USA leaves
(research, structures, and equipment), public and general assistance programmes, school health programmes, and millions of Americans facing medical bills that deplete
other state and local programmes. ACA=Affordable Care Act. their assets and drive them into debt. One in four non-

1436 www.thelancet.com Vol 389 April 8, 2017


elderly adults younger than 65 years (and one in three
with annual household incomes <$50  000) reported
difficulty paying medical bills in 2015; more than half of
these individuals owe more than $2500.85 People with
deductibles higher than $1500 (or families with
deductibles >$3000) and worse health than the overall
population are particularly at risk85,86 (figure 5), as are
African-Americans and Hispanics.86
Medical bills are a major contributor to household debt
and bankruptcy,14 comprising more than half of all unpaid
personal debts sent to collection agencies87 (figure 6). One
in ten families with medical bill problems has declared
bankruptcy.88 Although the uninsured are at greater risk
than the insured of declaring bankruptcy,39 most medical
bankruptcies involve debtors who are insured.14
Financial hardship is especially common among
people with serious illness.89 Among non-elderly adults
with cancer, more than a third borrowed money or went
into debt because of their treatment, and 3% filed for
bankruptcy.90 Such financial catastrophe appears to
increase mortality for treatable cancers,91 perhaps because
it leads to forgone care. Medicare92 and Medicaid93
coverage provide better (although still imperfect)
protection from financial hardship.
Medical bills force families to make difficult choices:
34% of insured Americans with difficulty paying medical
bills were unable to pay for food, heat, or housing, 15%
took out high-interest payday loans,94 and 42% took on
extra jobs or worked additional hours.85 Most people
reporting problems with medical bills say they have
skipped or delayed needed medical care.95 Moreover,
defaulting on medical bills and medical bankruptcies
often has long-term repercussions; these blemishes
remain on credit reports for many years, compromising
access to credit, insurance, housing, and employment.
Although medical costs impoverish many Americans,
this issue is not captured by the US Census Bureau’s
official measure of poverty. In response, the US Census
Bureau has introduced alternative poverty measures that
subtract medical costs and other mandatory expenses from
income, and add non-cash government aid (eg, housing
vouchers). These alternative measures indicate that more
Americans experience poverty than are reflected in official
statistics,96 with medical costs being the largest contributor
to the difference between the official and alternative
measures, pushing an additional 10 million Americans
below the poverty line.97
The medical system in the USA also influences
inequality as an employer of nearly 17 million Americans.
Although physicians and nurses are generally well paid,
many other health-care workers are not. The health-care
system employs more than 20% of all black female
workers; more than a quarter of these health-care
workers subsist on family incomes below 150% of the
poverty line, and 12·9% of them are uninsured
(Himmelstein DU; unpublished analysis of the 2015
Current Population Survey).
www.thelancet.com Vol 389 April 8, 2017 1437
Series
200 Family coverage: deductibles
Family coverage: premiums
180 Workers’ earnings
160
140
120
Growth (%)
100
80
60
40
20
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Figure 4: Growth in American workers’ earnings, premiums, and deductibles for private insurance coverage,
2002–14
Sources: Medical Expenditures Panel Survey43,44 for years 2002–14 (2007 data unavailable), and US Bureau of Labor
Statistics, Current Employment Statistics Survey80 (data from April, 2002, to April, 2014).
A longer lens on health reform
A century ago, medical care in the USA had little
influence on health or wealth. Burgeoning medical
capabilities and costs in the 20th century made health
care an industry ripe for corporate investment and profit.
The transformation from a largely charitable service to a
market-driven enterprise ensued.
Markets distribute goods on the basis of purchasing
power, and for mostly non-discretionary purchases,
such as medical care, this results in particularly lopsided
financial burdens. In many other wealthy countries,
social democratic and labour parties have successfully
implemented policies that offset these market
tendencies by creating national health programmes, or
by tightly regulating private insurers and health-care
providers. The USA does not have such a party, perhaps
because the low-income voters most buffeted by the
market are divided by racial animosities. After the
2010 passage of the ACA, congressional stalemates
blocked incremental reforms that might have restrained
medical markets and democratised care. Republicans,
now in control of both houses of Congress and the
executive branch in Washington, DC, promise to replace
the ACA with measures that are even more market-
friendly than the ACA, which would tilt care further
towards the wealthy.
The health-care dilemma in the USA, characterised by
unequal access and unfair financing, echoes that of the
1950s and 1960s, prior to the passage of Medicare and
Medicaid, when one in four Americans (and half of older
people and minorities) did not have health coverage.
After 8 years of Republican rule, the Democratic
President Kennedy was inaugurated in 1961. The
impetus for reform was bolstered by the popular
mobilisation for civil rights and enabled by the
Democratic Party’s landslide victory in the 1964 election.
 Series

60
53%

50 47%
Proportion of survey respondents (%)

40 37%

30
26% 26% 26%
22%
20%
20
15% 14%

10

0
Not disabled Disabled Lower High Insured Uninsured ≥$100 000 $50 000– <$50 000 Total, adults
deductible deductible 99 999 aged 18–64
years

Disability status Plan deductible Insurance status Household income

Characteristics

Figure 5: Share of adults in the USA aged 18–64 years reporting problems paying medical bills in 2015, by selected characteristics
Reproduced with permission from the Kaiser Family Foundation/New York Times Medical Bills Survey, 2016.85 High deductible defined as higher than $1500 for an
individual or higher than $3000 for a family.

60

52·1%
50
Proportion of unpaid personal debts (%)

40

30

20 17·3%

10 8·2%
7·3% 7·2%

2·2% 1·6% 1·5% 1·2% 0·6% 0·4% 0·3% 0·1% 0·1% 0·1% 0%
0
g
re

ed

lar

es

ail

ny
es

ive
cia

na
en

nc

te
sin
in

io
ca

iti

vic
t
sifi

pa
llu

ot
io
Re

an
nk

Un
an
m

ra
lea
il
lth

er

om
ce

at

m
Ut
s

su
rn

ar
Ba

Fin
cla

it
ls

uc

to
ea

or
or

ve

gu
In

ed

lc
na
Un

Ed

Au
rh

Go
al
ble

Oi
Cr
ue
rso
nt
lo

Ca

eq
Re

Pe
ica

Ch
ed
M

Type of creditor

Figure 6: Composition of unpaid personal debts sent to collection agencies in the USA, by type of creditor
Source: US Consumer Financial Protection Bureau, 2014.87

The 1965 passage of Medicare and Medicaid vastly students, fairer immigration laws, and the establishment
improved access to care and desegregated hospitals. But of the National Endowment for the Arts. The
these health-care initiatives were just one part of a broad redistributive agenda, dubbed the War on Poverty, also
legislative agenda that transformed American society, vastly expanded non-cash benefits such as food
including the Civil Rights and Voting Rights Acts, laws subsidies, free pre-school programmes for poor children,
that improved opportunities for women in universities and community health centres, and boosted social
and the military, the first major federal aid programmes security benefits, lifting 2·5 million senior citizens out
for local (particularly poor) public schools and college of poverty. When President Kennedy came into office in

1438 www.thelancet.com Vol 389 April 8, 2017


1961, 40 million Americans were poor. When his
sucessor President Johnson left office in 1969, that
number had fallen to 24 million. In 1972, the gap in
remaining life expectancy at the age of 60 years was only
1·2 years between men with incomes above and below
the median.2
Half a century on, neoliberal policies have eroded these
gains. Today, 43·1 million Americans are poor, many
health and social inequities persist, and some have
worsened. Even after the ACA’s coverage expansion—
reviewed elsewhere in this Series—27 million Americans
remain uninsured and, for many with insurance, access to
affordable care remains elusive. At the same time,
unneeded and even harmful medical interventions remain
common (due, in part, to the fragmented health-care
delivery system), bureaucracy consumes nearly a third of
health spending, and wealthy Americans consume a
disproportionate and rising share of medical resources.
Conclusion
Many physicians in the USA are working to advance
health-care justice. But increased efforts in this direction
are needed. The brave cadre of colleagues who face
constant threat for delivering abortion services (which
are disproportionately needed by poor women) must be
supported and augmented, especially as anti-choice
politicians now hold sway in Washington, DC. Doctors
should follow the lead of trainees, such as those in the
WhiteCoats4BlackLives movement, who have spoken out
against the structural racism that still tarnishes many
medical institutions and policies that deny care to
immigrants. Physicians should reflect on the ways we—
and the institutions we practice within—embrace or
evade the responsibility to care for the disadvantaged.
Doctors should also join in demanding reforms that
move forward, not backward, from the ACA. Republicans
aspire to roll back the law’s coverage expansions, fully
privatise Medicare and the VA, and give state
governments free rein to cut Medicaid—changes that
must be resisted to avoid a public health disaster.
However, Hillary Clinton’s 2016 presidential election
defeat suggests that defending the health-care status quo
cannot win the day. Moreover, proposals for incremental
steps that could cushion the worst inequities—such as
tighter insurance regulations, allowing a government
insurance plan to compete in the market, regulation of
drug prices, and extension of public coverage to
immigrants—failed to excite voters. Until November, 2016,
mainstream politicians and pundits deemed such steps
politically feasible, and more thoroughgoing reform
unattainable. Now, a more inspiring and egalitarian
vision—a health-care reform that address the problems
felt by most insured Americans—seems a more effective
rebuttal to the Republican mantra of “Repeal and replace
[the ACA]”. A bolder step towards health-care equality—
straight on to universal public insurance—could offer the
best way forward.98
www.thelancet.com Vol 389 April 8, 2017 1439
Series
Contributors
SLD, SW, and DUH developed and drafted the paper, contributed to
revisions, and approved the final manuscript.
Declaration of interests
DUH and SW were founders of, and remain active in, Physicians for a
National Health Program, a group that advocates for a single-payer
national health insurance system for the USA. DUH and SW served as
unpaid advisors to Senator Bernie Sanders during Sanders’ presidential
campaign. SLD declares no competing interests.
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Behavioral and Social Sciences and Education, Board on
Mathematical Sciences and Their Applications, Division on
Engineering and Physical Sciences, The National Academies of
Sciences, Engineering, and Medicine. The growing gap in life
expectancy by income: implications for federal programs and policy
responses. Sept 17, 2015. Washington, DC: National Academies
Press, 2015. http://www.ncbi.nlm.nih.gov/books/NBK321304
(accessed Jan 13, 2017).
84 Zallman L, Woolhandler S, Himmelstein D, Bor D, McCormick D.
Immigrants contributed an estimated $115.2 billion more to the
Medicare Trust Fund than they took out in 2002–09. Health Aff 2013;
32: 1153–60.
85 Hamel L, Norton M, Pollitz K, Levitt L, Claxton G, Brodie M.
The burden of medical debt: results from the Kaiser Family
Foundation/New York Times Medical Bills Survey. Jan 5, 2016.
Menlo Park, CA: Kaiser Family Foundation, 2016. http://kff.org/
health-costs/report/the-burden-of-medical-debt-results-from-the-
kaiser-family-foundationnew-york-times-medical-bills-survey
(accessed Jan 13, 2017).
86 Collins SR, Rasmussen PW, Doty MM, Beutel S. Too high a price:
out-of-pocket health care costs in the United States.
Commonwealth Fund Issue Brief 2014; 29: 1–14.
87 US Consumer Financial Protection Bureau. Consumer credit
reports: a study of medical and non-medical collections. December,
2014. http://files.consumerfinance.gov/f/201412_cfpb_reports_
consumer-credit-medical-and-non-medical-collections.pdf (accessed
Jan 13, 2017).
88 Sommers A, Cunningham PJ. Medical bill problems steady for U.S.
families, 2007–2010. Track Rep 2011; 28: 1–5.
89 Whitney RL, Bell JF, Reed SC, et al. Predictors of financial
difficulties and work modifications among cancer survivors in the
United States. J Cancer Surviv 2016; 10: 241–50.
90 Banegas MP, Guy GP Jr, de Moor JS, et al. For working-age cancer
survivors, medical debt and bankruptcy create financial hardships.
Health Aff 2016; 35: 54–61.
91 Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as
a risk factor for early mortality among patients with cancer.
J Clin Oncol 2016; 34: 980–86.
92 Yabroff KR, Dowling EC, Guy EP Jr, et al. Financial hardship
associated with cancer in the United States: findings from a
population-based sample of adult cancer survivors. J Clin Oncol
2016; 34: 259–67.
93 Hu L, Kaestner R, Mazumder B, Miller S, Wong A. The effect of the
Patient Protection and Affordable Care Act Medicaid expansions on
financial well-being. April, 2016. Cambridge, MA: National Bureau
of Economic Research, 2016. http://www.nber.org/papers/w22170
(accessed Jan 13, 2017).
94 Bickham T, Lim Y. In sickness and in debt: do mounting medical
bills predict payday loan debt? Soc Work Health Care 2015;
54: 518–31.
95 Baughman KR, Burke RC, Hewit MS, Sudano JJ, Meeker J,
Hull SK. Associations between difficulty paying medical bills and
forgone medical and prescription drug care. Popul Health Manag
2015; 18: 358–66.
96 Hutto N, Waldfogel J, Kaushal N, Garfinkel I. Improving the
measurement of poverty. Soc Serv Rev 2011; 85: 39–74.
97 Collins SR. New census poverty measure shows medical expenses
push 10 million more Americans into poverty. Nov 10, 2011.
http://www.commonwealthfund.org/publications/blog/2011/nov/
new-census-poverty-measure (accessed Jan 13, 2017).
98 Gaffney A, Woolhandler S, Angell M, Himmelstein D. Moving
forward from the Affordable Care Act to a single-payer system.
Am J Public Health 2016; 106: e1–2.
 Series

America: Equity and Equality in Health 2

The Affordable Care Act: implications for health-care equity
Adam Gaffney, Danny McCormick

Lancet 2017; 389: 1442–52
See Editorial page 1369
See Comment pages 1376
and 1378
This is the second in a Series of
five papers about equity and
equality in health in the USA
Division of Pulmonary and
Critical Care Medicine
(A Gaffney MD) and Division of
Social and Community Medicine
(D McCormick MD), Department
of Medicine, Cambridge Health
Alliance, Cambridge, MA, USA;
and Harvard Medical School,
Boston, MA, USA (A Gaffney,
D McCormick)
Correspondence to:
Dr Adam Gaffney, Division of
Pulmonary and Critical Care
Medicine, Department of
Medicine, Cambridge Health
Alliance, Cambridge, MA 02139,
USA
agaffney@challiance.org
Inequalities in medical care are endemic in the USA. The Affordable Care Act (ACA), passed in 2010 and fully
implemented in 2014, was intended to expand coverage and bring about a new era of health-care access. In this
review, we evaluate the legislation’s impact on health-care equity. We consider the law’s coverage expansion, insurance
market reforms, cost and affordability provisions, and delivery-system reforms. Although the ACA improved coverage
and access—particularly for poorer Americans, women, and minorities—its overall impact was modest in comparison
with the gaps present before the law’s implementation. Today, 29 million people in the USA remain uninsured, and
substantial inequalities in access along economic, gender, and racial lines persist. Although most Americans agree
that further reform is needed, the proper direction for reform—especially following the 2016 presidential election—is
highly contentious. We discuss proposals for change from opposite sides of the political spectrum, together with their
potential impact on health equity.
Introduction them.3,4 However, the USA entered the 21st century as an
Inequalities in health are rife in the USA. Disparities in outlier among high-income nations—the only one
life expectancy between the wealthy and the poor are without universal health coverage. The milestone
growing.1 Pernicious race-based health inequalities, the Affordable Care Act (ACA), signed into law by President
consequence of centuries of repression and exclusion, Obama in 2010, marked the beginning of a new era
endure. Meanwhile, middle-aged white Americans, of expanded health-care access. As a result of the
particularly those with less education, have experienced 2016 presidential election, however, it is unclear whether,
an unprecedented rise in mortality.2 Although a complex and to what extent, the ACA’s reforms will persist—or be
array of social factors underlies these inequalities, undone.
equitable access to health care could help ameliorate Unlike landmark health-care reforms in other English-
speaking nations, which created new universal, public

Key messages
• The Affordable Care Act (ACA) has nearly halved the share of Americans without
coverage. Disadvantaged groups including the poor, African-Americans, and Hispanics
saw gains, although stark health-care inequalities remain.
• Despite the ACA, financial barriers to care persist and might be worsening. High cost
sharing in the form of copayments, deductibles, and co-insurance obstructs access to
care and frequently leads to financial distress, or even ruin.
• The ACA expanded Medicaid—a public programme for the poor—improving access for
millions. However, 19 states opted out of the expansion, and limitations in the
Medicaid programme relegate many enrollees to a lower tier of access.
• The law improved access to contraception by mandating coverage for insured women.
Meanwhile, several states have imposed new restrictions that curtail access to family
planning and abortion.
• The ACA included a number of value-based delivery system provisions.
Their equity implications are not yet clear. However, some such pay-for-performance
programmes might siphon resources from hospitals and doctors that care for
disadvantaged populations.
• The 2016 election altered the political landscape. Republicans have proposed
market-based health reforms that would weaken protections for those with so-called
pre-existing conditions, decrease federal funding for Medicaid, further privatise
Medicare, and replace the ACA’s subsidies with more regressive tax credits. If
implemented, these policies would exacerbate health-care inequality.
• By contrast, by providing comprehensive coverage to everyone in the USA without cost
sharing, single-payer reform could reduce health-care inequalities. Although the
political climate is currently adverse to such a reform, it is supported by most Americans,
and might prove to be the most tenable proposal for change as political winds shift.
Search strategy and selection criteria
For information on the impact of the Affordable Care Act
(ACA) on health-care coverage, access, use, and disparities,
we relied on major health-care survey reports or publications
based on them, including the National Health Insurance
Survey, the Commonwealth Fund Biennial Health Insurance
Survey, the Commonwealth Fund Affordable Care Act
Tracking Survey, Gallup Healthways, the RAND Health Reform
Opinion Survey, the American Community Survey, the Urban
Institute’s Health Reform Monitoring Survey, and the
Employer Benefits Survey of the Kaiser Family Foundation.
We also identified articles published in English about health
disparities and the ACA in PubMed and the Web of Science by
searching for the keywords “Affordable Care Act” in
conjunction with one of the following: “disparity”,
“disparities”, “inequality”, “inequalities”, or “inequity” for the
dates Jan 1, 2010, to Oct 4, 2016. We did additional ad-hoc
searches to locate references relating to gender or sex and
racial inequalities and the ACA. We also identified relevant
references from the reference lists of selected papers, from
the libraries of the authors, and through the
recommendations of expert colleagues. Owing to limitations
on the numbers of references and the broad scope of the
topic, references were selected after consideration of their
importance and originality.

1442 www.thelancet.com Vol 389 April 8, 2017

 Series

Provision Estimated number affected

Coverage expansion
Dependant Family insurance plans must cover dependants up to age 26 years. 3 million people aged 19–25 years gained coverage.9
coverage provision
Medicaid Medicaid eligibility expanded to include all people with incomes below 138% of the 13 million people gained coverage.10
expansion federal poverty level.* However, states can opt out as a result of a 2012 Supreme Court
decision. 100% of the costs of the expansion paid for by the federal government initially,
gradually reduced to 90% by 2020.
Individual Individuals without coverage must buy a private plan or pay a tax. Certain exceptions 8·2 million people might become uninsured without this provision.11
mandate apply, including for economic hardship.
Employer mandate Employers with 50 or more full-time employees must provide coverage that meets Between 200 000 and 1 million people might lose employer-sponsored
certain criteria (see “cost and affordability” below). Those that do not offer coverage insurance without this provision.13
to >95% of their full-time employees and dependant children are taxed at US$2160 per
year per employee after the first 30 full-time employees, assuming one or more full-time
employees purchase a subsidised marketplace plan. Those that provide plans that do not
meet criteria for affordability and minimum value are taxed at $3240 per year for each
employee that receives a premium tax credit, but no more than $2160 per employee
after the first 30 employees.12
Health insurance market reforms
Marketplaces Sets up online marketplaces for the sale of insurance plans to individuals and small 12 million people gained coverage through the health insurance exchanges.10
businesses. Plans sold on the marketplaces must cover ten essential health benefits.
Plans purchased on the marketplaces are eligible for premium and cost-sharing subsidies
(see “cost and affordability” below).
Guaranteed issue Insurers cannot base premiums on health (eg, pre-existing conditions) or gender. Premiums Uncertain
of plans can be set by age (up to three times difference in premiums between young and old
enrollees), smoking status, benefits tier (see “cost and affordability” below), location, and
whether plan is for an individual or a family.
Benefit limits Prohibits annual and lifetime limits on benefits. 105 million people had plans with lifetime limits pre-ACA.14
Preventive health Specified preventive health-care services provided without cost sharing. 76 million people became eligible for free preventive services.15
services
Provisions Outlaws gender rating, in which women are charged higher premiums than are men. 8·7 million women might benefit from expanded maternity care coverage and
impacting gender Maternity care considered an essential health benefit. Some reproductive health-care 45 million women with expanded preventive services access as of 2012.16
equity services (including contraception) considered preventive, and hence must be provided
without cost sharing.
Cost and affordability
Employer- To meet the employer mandate requirement, plans must meet affordability criteria 155 million people had employer-sponsored coverage in 2016.10
sponsored plans (premium ≤9·66% of income), benefit criteria, and minimum value criteria (plan covers
at least 60% of total medical expenses on average).12 Affordability criteria pertain only to
individual, not family, coverage. Thus, cost of family coverage might exceed
9·66% threshold.
Marketplace plans Premium subsidies available on a sliding scale to those earning between 100% and 400% of 10 million people receive premium subsidies.10 7·2 million people receive
the federal poverty level. Additional cost-sharing subsidies that reduce copayments and cost-sharing subsidies that increase actuarial value; these plans also have lower
deductibles available to those earning up to 250% of the federal poverty level. Sets following out-of-pocket maximums.17 However, a lower court recently ruled in favour of a
actuarial values for plans: 90% for platinum plans, 80% for gold plans, 70% for silver plans, Congressional Republican challenge to the legality of these subsidies, a ruling
and 60% for bronze plans. Sets out-of-pocket maximums: for 2017, these were $14 300 for that would end these subsidies unless it is overturned by a higher court.
family plans and $7150 for individual plans, with lower limits for those earning less
than 250% of the federal poverty level. Some employers with less than 25 full-time
employees eligible for subsidies for tax credits to buy insurance on small business
marketplaces.12
Delivery system reforms
Pay-for- Financial rewards and penalties for hospitals based on quality metrics—eg, Hospital Uncertain
performance Readmissions Reduction Program, Hospital Value-Based Purchasing Program, and
reforms Hospital-Acquired Condition Reduction programme.
Accountable care Encourages providers to form ACOs (responsible for a panel of Medicare enrollees) that Uncertain
organisations share in savings with Medicare if they reduce expenditures—eg, Medicare Shared Savings
(ACOs) Program, Pioneer ACOs.
Provisions Increased funding for community health centres. Reduced funding for Disproportionate Uncertain
affecting Share Hospital programme.
safety-net
institutions

ACA=Affordable Care Act.*All undocumented immigrants and many legal immigrants are excluded.

Table 1: Summary of selected ACA provisions

www.thelancet.com Vol 389 April 8, 2017 1443

 Series

See Online for infographic programmes, the ACA sought to expand access by Coverage expansion under the ACA
www.thelancet.com/ building on the existing financing system. To this end, Universal coverage is a foundation of equitable health
infographics/us-health
the ACA expanded the Medicaid programme for the poor care. Without it, the uninsured face the unremitting
and private insurance for others, while mandating threat of financial ruin from illness or accident. Yet the
changes in insurance regulation and provider payment hazard is not only monetary; uninsurance is associated
methods. with increased mortality,18,19 poor overall health, and an
We explore the reforms of the ACA using the theoretical increase in depressive symptoms and adverse
framework of health-care equity: the perspective that care cardiovascular outcomes.20 Moreover, unequal health-
should be available to all on an equal basis.5 Health-care care access often exacerbates health inequalities that
equity can be construed along three axes: equitable arise from poverty, racial discrimination, and poor
access, equitable use (for those with similar needs), and education.
equitable quality.5 Because many people do not have The ACA expanded insurance coverage in two major
insurance—and because even those with insurance face ways. First, it broadened eligibility for Medicaid, an
high costs when they seek care—health-care access has insurance programme for the poor funded by federal and
long been grossly inequitable in the USA. In 2010, for state taxes, which is administered by state governments.
instance, 48·6 million people were uninsured.6 The Prior to the ACA, many states limited Medicaid eligibility,
uninsured were mostly of low or middle income, and covering only very poor people in specific categories
disproportionately black or Hispanic;6,7 the ACA was (eg, children and some of their parents, disabled people,
expected to particularly benefit these groups.8 and pregnant women). By contrast, under the ACA, all
Here, we review the ACA’s coverage expansions, citizens with incomes up to 138% of the federal poverty
insurance market reforms, cost and affordability provisions, level became eligible for Medicaid coverage commencing
and delivery system reforms (see table 1 for an overview). in 2014.
We explore the multifold ways in which the ACA moved Second, the ACA mandated that uninsured citizens
the US health system towards increased equity across purchase private insurance (or pay a fine), and offered
income, gender, sex, and race and ethnic groups. At the some subsidies to those with incomes between 100%
same time, we document the ways in which it has fallen and 400% of the poverty level to offset the costs of
short. We conclude with an assessment of the reform’s insurance premiums. The law also established online
prospects in light of the 2016 presidential election, and of insurance exchanges or marketplaces through which
proposals for change moving forward. individuals could purchase regulated, subsidised, and

100 Number (millions)

Percentage
90

80
Number and percentage of uninsured people

70

60

50

40

30

20

10

0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Number (millions) 41·0 39·3 38·7 41·3 40·2 41·5 43·6 42·5 41·2 43·6 43·1 43·8 46·3 48·6 46·3 45·5 44·8 36·0 28·6
Percentage 15·4 14·6 14·2 14·9 14·3 14·7 15·2 14·7 14·2 14·8 14·5 14·7 15·4 16·0 15·1 14·7 14·4 11·5 9·1

Figure 1: Number and percentage of people uninsured in the USA, 1997–2015

Uninsured defined as uninsured at time of interview. Two different methods were used in 2004 to calculate the number of insured; the estimates are similar, and this
chart uses the first method. These data rely on surveys of civilian, non-institutionalised households. See source21 for further details on methodology.

1444 www.thelancet.com Vol 389 April 8, 2017


standardised plans. Additionally, the ACA imposed an
employer mandate that required large employers to offer
health coverage to their employees or pay a fine.12,13
Finally, the law required that family insurance policies
cover children younger than 26 years of age.
Most coverage expansion provisions became effective
in 2014, and evidence suggests that they improved health-
care equity in several domains (table 1). For instance, the
number of uninsured individuals fell from about
48·6 million (16% of the US population) in 2010 to about
28·6 million (9·1%) in 2015 (figure 1).21–25 Most of this
improvement has been the result of the Medicaid
expansion. Of the 22 million who gained insurance as a
result of the ACA, 13 million were insured through
Medicaid.10 At the same time, several measures of
access, use, and health outcomes have also improved.
After implementation of the ACA, more people reported
that they could afford medications and had a physician,
fewer reported problems affording care, and self-reported
health status improved.23 Along similar lines, the
percentage of non-elderly (ie, <65 years of age) adults who
avoided needed care because of cost fell from 43% in 2012
to 36% in 2014.25 Meanwhile, the percentage of non-elderly
adults who had difficulties with medical bills or medical
debt declined from 41% to 35% over these 2 years.25
As had been hoped, insurance coverage and metrics of
access and use particularly improved for the poor
(<100% federal poverty level) and the near-poor (≥100%
and <200% of the federal poverty level),6 blacks and
Hispanics,6,23,26–28 women of childbearing age, and young
families.29–31 The requirement that family policies cover
children aged 18–25 years—a population that has long
had especially high rates of uninsurance—was
implemented in 2010 and modestly reduced uninsurance
rates32–34 and increased access32 and use35 among young
adults. However, despite this provision, the uninsurance
rate in 2014 among adults aged 19–25 years was
still 17·1%36—substantially higher than that of the overall
population.
Despite this progress, the gains in coverage and access
have been modest compared with the size of the gaps prior
to the law’s implementation. Further gains are not on the
horizon: according to the Congressional Budget Office,
even if the ACA were not altered or repealed, 28 million
people would remain uninsured in 2024 and beyond.10
Moreover, several metrics indicate that health-care
access remains inequitable. With respect to racial
disparities, in 2015 the uninsurance rate among adults
aged 18–64 years remained far higher for Hispanics (27·7%)
and non-Hispanic blacks (14·4%) than for non-Hispanic
whites (8·7%),6 showing that long-standing racial and
ethnic inequalities have been attenuated but by no means
eliminated.27,28 Gains in mental health and substance
abuse care were even weaker. Blacks, for instance,
saw no increase in mental health treatment following
implementation of the ACA, whereas no racial group saw
an increase in substance abuse treatment.37 Finally,
www.thelancet.com Vol 389 April 8, 2017 1445
Series
50 Poor
Near-poor
45 Non-poor
40
35
Percentage uninsured
30
25
20
15
10
5
0
2010 2011 2012 2013 2014 2015
Year
Figure 2: Uninsurance rates in the USA by poverty status for individuals younger than 65 years
Uninsured defined as uninsured at time of interview. Poor defined as family income less than 100% of the
federal poverty level (FPL), near-poor as greater than or equal to 100% and less than 200% FPL, and non-poor as at
least 200% FPL. Data for those with unknown poverty status not shown here. See source6 for details on methodology.
undocumented immigrants are excluded from the ACA’s
insurance expansion.
Additionally, inequalities by economic class also persist.
Among non-elderly adults, 7·6% of the non-poor were
uninsured in 2015 compared with 25·2% of the poor and
24·1% of the near-poor (figure 2).6 Despite afore­mentioned
improvements, many Americans remain unable to afford
care. In 2014, 23% of non-elderly adults reported having
skipped a medical visit, and 19% were unable to fill a
prescription or undergo a recommended treatment or test
because of cost.25 Low-income people, unsurprisingly, fare
even worse.25 In 2015, 44·8% of non-elderly low-income
adults had unmet medical needs owing to costs, and
24·2% faced difficulties with medical bills.38
The so-called narrow networks of doctors and hospitals
covered by most marketplace plans also impede
equitable health-care access. Narrow networks allow
insurers to control costs: they use the threat of exclusion
from networks to extract price concessions from doctors
and hospitals.39 However, narrow networks can also be
used by insurers to exclude providers (eg, quaternary
referral centres) that are likely to attract expensively ill
and hence unprofitable enrollees. In 2015, for instance,
among the dozens of insurance plans offered on
New York’s marketplace, only one—from a consumer
cooperative that subsequently suffered financial
collapse—covered care at the city’s leading cancer centre,
Memorial Sloan Kettering, whereas no plans included
the prominent New York Presbyterian system.40
Although some people see narrow networks as a
mechanism for cost control and—theoretically—quality
improvement,41 these networks are sometimes too sparse
to provide access to needed specialty care.42,43
The ACA’s Medicaid expansion, which targeted the
poor and near-poor (many of whom are racial or ethnic
 Series
minorities), had great potential to improve health equity.
However the Supreme Court’s 2012 decision allowing
states to opt out of the Medicaid expansion diminished
its effect. At the time of writing, 19 states44—many of
them southern states with large minority populations
and poor records on health-care access and outcomes,
particularly for the poor45—have opted out. Studies
comparing non-expansion to expansion states have
found less improvement in health-care coverage, use,
and access among the former.22,46,47 Estimates suggest that
state opt-outs will lead to thousands of unnecessary
deaths annually,48 further compounding existing
geographical and racial health inequalities. Notably, the
generosity of Medicaid benefits has traditionally varied
from state to state.
Additionally, even in states that have implemented the
Medicaid expansion, the low fees it offers doctors often
consign Medicaid-insured patients to second-class status.
Many physicians will not accept Medicaid,49 and even
when they do, might not offer Medicaid patients equal
treatment. For instance, waiting times for new
appointments are longer for Medicaid patients than for
those with private plans.50 Some studies have also found
evidence suggesting pervasive segregation of care by
insurance status and race: for instance, some large
academic centres have maintained separate (and thus
invariably unequal) clinic systems for Medicaid and
privately insured patients.51 More generally, physicians
are significantly less likely to accept Medicaid in areas
with high percentages of non-white people or high levels
of racial segregation than are physicians in other areas.52
To address such disparities, the ACA temporarily
(for 2 years) boosted Medicaid reimbursements for
primary care physicians.53 A secret shopper study
conducted before and during this change found an
increase (from 58·7% to 66·4%) in the proportion of
practices willing to schedule appointments to Medicaid
enrollees; this increase was an improvement, but still
well below the 86% of privately insured callers who were
offered an appointment.53 Regardless, with the expiration
of the fee boost, this modest improvement will probably
be reversed.
In summary, although Medicaid offers crucial health
coverage to the poor, it often provides an inferior and
separate tier of access to providers. Even if Medicaid were
expanded in all 50 states, the goal of health-care equity
would not be met.
Health insurance market reforms
Discriminatory pricing—by age, gender, or health
status—has long characterised the US private insurance
market. In the past, many insurers charged older adults
(ie, price increasing with age) and women higher
premiums, excluded coverage of maternity care,54 refused
to enrol individuals with medical problems (so-called
pre-existing conditions), and set annual or lifetime caps
on insurance payments. In addition to its coverage
1446 www.thelancet.com Vol 389 April 8, 2017
expansion, the ACA included provisions intended to
reduce these discriminatory practices (table 1).
First, the law outlawed underwriting (ie, increasing
premiums or refusing coverage) on the basis of gender
or health status. Second, among non-group plans
(ie, plans purchased by individuals, not provided by
employers), premiums for older enrollees (≥64 years of
age) cannot exceed those for young adults (≥21 years of
age) by more than a factor of three. Third, the ACA
required insurance policies to pay for preventive services,
including contraception, without cost sharing (ie, out-of-
pocket payments) and to cover maternity care.16 Fourth,
the legislation prohibited annual and lifetime caps on
insurance payments, improving financial protection
against catastrophic illness.
Despite these provisions, increasingly subtle forms of
insurance discrimination against the sick persist. Insurers
continue to tailor their benefit packages (and, as described
above, their provider networks) to discourage high-cost
patients from choosing or remaining in their plan. For
instance, some insurers require extraordinarily high
patient copayments for essential drugs (eg, antiretrovirals
and antipsychotics) needed by expensively ill patients. HIV
patients enrolled in such plans pay, on average, US$4892
annually out-of-pocket per drug.55 Such pricing tactics
effectively skirt regulations prohibiting discrimination
against patients with pre-existing conditions.55 Some major
insurers have also told insurance brokers that they will
cease paying commissions to brokers for enrolling
customers in more comprehensive, low cost-sharing plans
because such plans attract patients in poor health
anticipating large medical expenses.56
The ACA has improved reproductive health-care access,
yet substantial gaps persist. From 2012 to 2015, the percent
of reproductive-age women who were uninsured fell from
18·9% to 11·5%.30 The mandate that insurance fully cover
contraceptives has reduced out-of-pocket spending for
such drugs and devices, yet many insurers still exclude
coverage for some items (eg, male condoms and the
morning-after pill).57,58 And whether or not contraception-
related care is actually provided without cost sharing—as
required by the ACA—can depend on the vagaries of how
physicians code particular office visits.57
The ACA’s promise of full coverage for contraceptives
was also eroded by a 2014 Supreme Court decision
excusing employers who claim religious objections from
paying for such coverage for their employees. Data
suggest that this contraception exclusion loophole has
left some women unable to obtain intrauterine devices,58
underscoring the risks intrinsic to a system that relies on
employers to provide and oversee their employees’ health
coverage.59
These problems have been exacerbated by some state
governments’ moves to curtail access to contraception
and abortion, particularly for poor women. A number of
states have imposed onerous requirements on abortion
clinics, forcing many to close, and have sharply reduced

funding for family planning programmes.60 In one such
state—Texas—the cuts resulted in a sharp reduction in
the use of long-acting contraceptives and an increase in
births among those reliant on injectable contraceptives.61
In addition, preliminary evidence suggests the states
with the most severe abortion restrictions are seeing an
increase in women investigating and possibly pursuing
self-induced abortions.62 These trends might worsen as a
result of the 2016 election, given Republican proposals
aimed at reducing abortion access.63
Health-care affordability
Despite the ACA’s coverage expansions and insurance
market reforms, costs remain a potent impediment to
health-care equity, even for people with insurance. High
out-of-pocket costs compound both health-care inequality
and income inequality. With respect to the former, a large
body of research demonstrates that cost sharing deters
the use of clinical services, particularly for low-income
groups.64–66 With respect to the latter, cost sharing
exacerbates economic inequality because it takes a greater
proportion of income from the poor than from the
wealthy67—an issue addressed elsewhere68 in this Series.
Some provisions of the ACA do, notably, lower the
burden of cost sharing for certain services (table 1). As
described above, the ACA requires insurers to fully cover
certain preventive services69 and this appears to have
increased their uptake.70 However, when screening tests
uncover problems—for instance, a mammographic
opacity or hyperglycaemia—subsequent work-up and
treatment can result in onerous cost sharing. Table 2
displays the average deductibles (the amount patients
need to pay before insurance kicks in) for employer-
sponsored plans and for the plans offered on the ACA’s
insurance marketplaces.
Regarding employer-sponsored plans, over the past
decade the average deductible rose by 255%,72 and actual
household outlays for cost sharing rose 77%.73 The ACA’s
failure to reverse the trend toward rising cost sharing is
unsurprising for several reasons. First, under the ACA,
the actuarial value—ie, the percentage of all health-care
costs paid by the insurer for plan members, on average—
for employer-sponsored plans can be as low as 60% and
still meet the requirements of the employer mandate.13
Thus, employees with a 60% actuarial value plan still pay,
on average, 40% of their health-care costs out-of-pocket.
Second, the ACA imposed a new excise tax (the so-called
Cadillac tax) on employer-sponsored insurance plans
with premiums above a certain threshold. These plans
are deemed luxurious by virtue of their relatively high
premiums and comprehensive benefits, earning them
the Cadillac label. However, over time, an increasing
percentage of typical plans will be subject to the tax:
by 2028, an estimated 42% of employers will have at least
one insurance plan affected by the tax unless they
trim costs.74 Although Congress postponed the tax
until 2020, employers will probably respond to it by
www.thelancet.com Vol 389 April 8, 2017 1447
Series
Single coverage Family coverage
Marketplace plans
Bronze $5731 $11 601
Silver $3117 $6480
Gold $1165 $2535
Platinum $233 $468
Employer-sponsored plans
HMO $1025 $2758
PPO $958 $2012
POS $1230 $2467
HDHP/SO $2099 $4332
All plan types $1318 Not applicable
Marketplace plans: deductibles are for 2016 and do not reflect cost-sharing
subsidies, which are available to households earning less than 250% of the federal
poverty level. Data from HealthPocket.71 Employer-sponsored plans: deductibles
are for 2015, and only reflect deductibles for those plans with a general annual
deductible. If plans with no deductible are averaged in, the average overall
deductible is $1077 for single coverage plans (vs $1318 for all plan types among
plans with a general annual deductible). The employer-sponsored family
deductible is for plans with aggregate, not per person, deductibles. Data from the
2015 Employer Health Benefits Survey.72 Costs expressed in US$. HMO=health
maintenance organisation. PPO=preferred provider organisation. POS=point of
service plan. HDHP/SO=high-deductible health plan with a savings option.
Table 2: Average annual deductibles for private insurance by metallic tier
(marketplace plan) or plan type (employer-sponsored plans)
raising copayments and deductibles in order to keep
premiums below the threshold at which they incur the
tax10,74 (Republicans previously proposed replacing the
Cadillac tax with something similar—a cap on the tax-
deductibility of employer-sponsored health insurance
plans63—though their March, 2017, bill [described below]
would have just delayed implementation of the tax).
For people with non-group plans, most of which are now
obtained through the ACA’s marketplaces, cost sharing is
even more onerous. The ACA regulates this cost sharing in
a number of ways. First, the law sets the actuarial value of
marketplace plans at four metallic levels: 90% for platinum
plans, 80% for gold, 70% for silver, and 60% for bronze
(table 1). Second, it mandates caps on out-of-pocket
spending (after premiums) for plans sold on the
marketplace (in 2017, the out-of-pocket maximums were
$14 300 for a family and $7150 for an individual).17 Third, in
addition to the subsidies that reduce premiums for
enrollees earning less than 400% of the federal poverty
level, the law provided a second set of subsidies to offset cost
sharing for those earning less than 250% of the federal
poverty level.17 These subsidies, whose legality is currently
under challenge from Congressional Republicans,
effectively increase the actuarial value of the silver plan to
between 73% and 94% (depending on enrollee income).17
Despite these regulations and subsidies, those with
modest incomes sometimes still find themselves
financially squeezed.75 According to one survey,76 almost
half of of Americans would have to borrow money or sell a
possession to pay a surprise expense of $400—an amount
well below the cost sharing resulting from a single test or
 Series
hospitalisation under many plans. Similarly, only 37% of
non-elderly, non-poor households have the liquid assets
necessary to meet the ACA’s out-of-pocket maximums for
a given year.77 Among poor families with at least one
uninsured family member, that percentage is even lower.77
Finally, these out-of-pocket maximums apply only to care
received from in-network providers. Cost sharing for care
obtained out of network—even when medically
appropriate—has no limit.
Cost sharing in marketplace plans is generally higher
than in employer-sponsored plans. For example, one
study78 estimated that for people with a chronic condition,
switching from an employer-sponsored plan to a silver-
level marketplace plan would double out-of-pocket
spending on drugs. Without subsidies, average deductibles
for silver plans in 2016 averaged over $3000 for individuals
and around $6500 for family plans (table 2).17,71 Even with
cost-sharing subsidies, patients face high costs at the
point of use; a 40-year-old man earning $25 000 a year, for
instance, would still face a median annual deductible
of $2500 and an out-of-pocket maximum of $5000.17
Finally, the effect of the ACA on health-care
affordability for the poor and near-poor covered by
Medicaid is complex. On the one hand, traditional
Medicaid imposes virtually no cost sharing on its
impoverished enrollees. Hence, many of those covered
by the ACA’s Medicaid expansion have gained access to
care without out-of-pocket costs. However, several states
refused to expand Medicaid unless the Obama
administration granted them permission to impose new
premiums or cost-sharing requirements.79 For instance,
Indiana requires that enrollees deposit a monthly
payment into a health savings account. Though the
amount is small, it is substantial for those with meagre
incomes.80 The ramifications are serious for those who
do not or cannot make these payments. People earning
between 100% and 133% of the federal poverty level who
fail to make their payments lose all benefits for
6 months.80 For those earning less than poverty, the
penalty is less severe: they only lose dental and vision
coverage, but are also subsequently obliged to pay
new copayments for doctors’ visits, hospitalisations,
and medications.80 Notably, this programme was
implemented by Governor (now Vice-President)
Mike Pence, on the advice of Seema Verma, the new
head of the Centers for Medicare & Medicaid Services.81
It might be thus be a harbinger of national changes to
Medicaid.
ACA initiatives to maximise value
In addition to expanding coverage and regulating
insurance, the ACA aimed to restructure the health-care
delivery system to maximise value; these provisions also
might have implications for health-care equity. Delivery
system reforms (table 1) initially affected only the federal
Medicare programme, which has covered virtually all
persons aged 65 years and older since 1965. However,
1448 www.thelancet.com Vol 389 April 8, 2017
private insurers and state-run Medicaid programmes are
following Medicare’s lead.
Proponents of so-called value-based reform typically
emphasise paying for value, not volume, using financial
risk-sharing arrangements that offer providers bonuses
for cutting costs and exact fines if they fail to do so,
together with pay-for-performance (P4P) that rewards or
penalises providers based on their scores on quality
metrics. The common thread linking these ideas is that
they are intended to reduce costs by penalising the
provision of excess care, while relying on P4P to ensure
that cuts in the amount of care do not compromise
quality.
New value programmes can be divided into two
overlapping categories: changes in the manner providers
are paid, and a restructuring of health-care delivery.82 The
former consists of the ACA’s new P4P Medicare schemes
for hospitals,83 as well as a subsequent value reform—the
Medicare Access and CHIP Reauthorization Act of 2015,
which will base 18% of payments to office-based
physicians on their P4P scores and cost savings. The
latter category includes incentives in the ACA to form
accountable care organisations (ACOs; described below),
together with changes in spending on safety-net
providers that care for disadvantaged populations. These
programmes have the capacity to affect health-care equity
in a variety of ways.
The ACA’s P4P initiative involved creating three new
P4P Medicare hospital programmes—the Hospital
Readmissions Reduction Programme (HRRP), the
Hospital Value-Based Purchasing (HVBP) programme,
and the Hospital-Acquired Condition Reduction
Programme— that in conjunction can result in
penalties of 6% of total Medicare reimbursements by
2017.83 Although upgrades of quality for all Americans,
particularly the underserved, is a priority, it is far from
clear that these programmes will accomplish this.
Indeed, such P4P programmes could exacerbate health-
care inequality by penalising already cash-strapped
safety-net providers; they serve disadvantaged patients
whose poor health outcomes could arise from adverse
social conditions rather than substandard care. P4P
might also backfire if providers avoid disadvantaged
and non-compliant patients who drag down their
scores.84
The overall effect of the ACA’s P4P initiatives on health
equity remains uncertain. A number of early studies,
however, raise concerns that two of the ACA’s
programmes (HRRP and HVBP) selectively penalise
safety-net hospitals.85–88
Moreover, it is unclear whether P4P metrics accurately
measure quality. In California, for instance, safety-net
hospitals were fined under HRRP because their patients
with heart failure, pneumonia, and myocardial infarction
had elevated readmission rates.88 However, paradoxically,
these safety-net hospitals also had lower 30-day mortality
for all three conditions.88

Some argue that P4P programmes should statistically
adjust quality scores for patients’ socioeconomic status,89
although Medicare’s administrators have thus far opposed
such adjustment. However, although socioeconomic
status adjustment might make P4P fairer, capturing the
complex impacts of socioeconomic status on P4P
measures is a formidable task. And even if adjustment for
socioeconomic status confirmed that safety-net hospitals
delivered poor quality care, an appropriate response
might be to increase, not decrease, the resources available
to these institutions.
The ACA and delivery system change
The push for structural changes in the delivery system—
the second element of the ACA’s value-based reforms—
is embodied in new Medicare programmes that
encourage the formation of ACOs. These organisations,
which encompass both hospitals and doctors, contract
with Medicare to assume financial risk for all of the
health care received by a panel of Medicare enrollees.
The ACO strategy has notable parallels to the health
maintenance organisation strategy that gained both
prominence and notoriety in the 1980s and 1990s.90 Both
health maintenance organisations and ACOs reward
providers for reducing their patients’ use of care.90 ACOs
also incorporate P4P, which supporters assert will not
only protect patients from incentives to skimp on care,
but could also improve quality across the board, thereby
diminishing health-care inequality.91
Others, by contrast, have argued that ACOs could have
“the unintended consequence of reinforcing health care
disparities”.92 For instance, if profitable hospitals and
practices that serve wealthier patients acquire and merge
with other similarly profitable providers, the segregation
of disadvantaged patients might become only more
entrenched.92 For now, however, it is too early to judge the
equity effects of the ACO strategy.
Finally, the ACA’s delivery system reforms included
two additional measures directed at safety-net providers,
with more immediate equity implications (albeit in
different directions). On the one hand, the law earmarked
$11 billion in additional funding for the approximate
1300 federally subsidised community health centres,93 a
provision inserted by Vermont Senator Bernie Sanders.94
These clinics, located in medically underserved areas,
serve about 24 million patients annually.93 On the other
hand, the ACA reduced funding for the Disproportionate
Share Hospital (DSH) programme, which provides
supplemental funding for hospitals in which a large
share of patients have Medicaid (which pays low fees and
is also a marker for hospitals that care for the uninsured).95
The ACA’s drafters assumed that the need for these
subsidies would decline as coverage was expanded. Yet
safety-net hospitals continue to care for many uninsured
and underinsured patients, particularly in states that
refused to expand Medicaid or have many immigrants
whom the ACA’s coverage expansion excluded.
www.thelancet.com Vol 389 April 8, 2017 1449
Series
Looking ahead: health-care equity in the Trump era
The 2016 election dramatically changed the political
landscape. Republicans have long vowed to repeal the
ACA and replace it with market-based solutions, but with
the election of Donald Trump—a billionaire businessman
whose campaign rhetoric was perceived by many as
trafficking in crude bigotry—the prospects for repeal
suddenly improved. The form that the replacement
would take was unclear until March 6, 2017, when the
Republican House, led by Speaker Paul Ryan, released a
bill called the American Health Care Act (AHCA).96–98 Yet
Ryan’s bill was to experience a rapid demise. It was
assaulted by hard-right Republicans in the House of
Representatives for not going far enough, and it lost
support from Republican moderates after Ryan attempted
to mollify conservatives by modifying the bill. On
March 24, Ryan and Trump cancelled the scheduled vote
on the bill.
For the ACA’s supporters, this news was met with
much applause, although it is not entirely clear that the
AHCA will remain in the dustbin of history. Regardless,
the AHCA—or something resembling it—will probably
serve as the model for right-wing health-care reform in
the years to come, and is worth briefly reviewing.
The AHCA,96–98 to the surprise of some, would actually
have maintained much of the overall structure of the
ACA, including insurance regulations such as the one
protecting those with pre-existing conditions. Like the
ACA, the Republican bill would also have provided tax
credits to offset the cost of private health insurance
premiums for those not eligible for employer-paid
coverage. But because these more regressive credits
would not have been tied to the price of insurance (unlike
those of the ACA), they would have been inadequate to
cover the cost of coverage for many Americans, especially
those who were older or who had lower incomes.96
The AHCA would have also transformed the Medicaid
programme for the poor. Beginning in 2020, federal
funding for the Medicaid expansion would have been
substantially reduced. At the same time, federal funds
would have been allocated to states using either a per-
capita formula or a “block grant”,99 replacing the current
matching system that bases the federal contribution on the
actual cost of care delivered. These changes would have
slashed federal funding of Medicaid by $839 billion over a
decade,100 forcing states to reduce the comprehensiveness
of their Medicaid coverage, cut eligibility, or both.
Finally, in a last-minute maneuver intended to placate
hard-right conservatives, a provision was inserted
undermining the ACA’s requirement that plans cover
“essential health benefits”, which would have promoted
the sale of bare-bones plans.
Overall, these provisions would have transformed
coverage, providing a defined contribution to insurance
premiums rather than a defined set of covered benefits,
and they would have slashed Medicaid, effectively so as to
fund hundreds of billions of dollars in tax breaks96,100 to
 Series
the rich and health-care corporations. They also would
have dramatically increased the number of the uninsured
by an additional 24 million people.96,100
By reducing protections for the sick and those with
lower incomes, the AHCA would clearly have exacerbated
health-care inequalities; those who care about health-care
equity will certainly oppose such measures. At the same
time, however, the political wisdom of championing the
health-care status quo seems dubious. Although the
AHCA was profoundly unpopular, it is also clear that
voters want health care to change—a sentiment that
seems reasonable in view of the enormous problems that
persist despite the ACA’s advances. Hence, equity-
minded advocates might best counter the Republican
agenda with a forward-looking health-care agenda of
their own. A single-payer, Medicare-for-all reform—
championed by Senator Bernie Sanders during his
upstart presidential campaign, as well as by many
physicians101 and the nation’s largest nurses union—
would, in our view, best address health-care inequalities.
Such reform would replace the ACA’s patchwork of
coverage provisions with a tax-funded universal
programme. It would comprehensively cover all US
residents without cost sharing (as is currently done in
Canada and the UK), eliminating financial barriers to
care. Importantly, it would also end inequalities in access
based on type of insurance, and probably reduce both
economic4 and racial102 health-care inequalities. Although
passage of such thoroughgoing reform is unlikely in the
near term, it might be the most feasible option once
political winds shift and politicians catch up with the
views of the public: single payer, after all, is already more
popular than the ACA, favoured by 58% of the US
public.103
Conclusion
Decades ago, Julian Tudor Hart noted that “the availability
of good medical care tends to vary inversely with the
need of the population served”.104 His observation, derived
largely from experience in the UK, aptly describes US
health care.
In 2010, prior to the ACA, one in six Americans was
uninsured.6 Insurers could—and often did—discriminate
against older and sicker individuals as well as women.
Racial inequities in coverage and access were pervasive.
Illness often led to financial ruin. And limited health-
care access among the uninsured resulted in tens of
thousands of unnecessary deaths annually18—and
incalculable suffering for many more.
Through a patchwork of provisions, the ACA has
ameliorated the situation, particularly benefiting blacks,
Hispanics, and the poor. Yet serious deficiencies have
persisted. Many people remain uninsured and
underinsured. Wealth continues to be a crucial factor in
determining health and access to medical care. Narrow-
network insurance plans bar many from care at leading
hospitals and from the doctors of their choice. Patient
1450 www.thelancet.com Vol 389 April 8, 2017
cost sharing, a regressive form of funding that is on the
rise, often forces non-wealthy families to choose between
health care and other necessities. And despite the ACA’s
Medicaid expansion aiding millions of Americans, the
programme continues to consign poor patients to a
separate, and sometimes lower, tier of care.
Change is needed. However, the market-based reforms
proposed by Republicans would callously cut coverage
and exacerbate already pernicious inequities. By contrast,
a thorough overhaul of US health care—universal,
comprehensive, tax-funded coverage—remains the best
reform option to close the equity gap.
Contributors
Both authors contributed equally to the preparation of the manuscript.
Declaration of interests
Both authors report research grant support from the National Institutes
of Health, and are active members of Physicians for a National Health
Program, an organisation that advocates for single-payer health care in
the USA.
Acknowledgments
We thank David Himmelstein and Steffie Woolhandler for their
assistance with this manuscript.
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 Series

America: Equity and Equality in Health 3

Structural racism and health inequities in the USA: evidence
and interventions
Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett

Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy Lancet 2017; 389: 1453–63
makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public See Editorial page 1369
discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the See Comment pages 1376
third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to and 1378
discuss research and interventions that grapple with the implications of what is known as structural racism on This is the third in a Series of
population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial five papers about equity and
equality in health in the USA
discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit,
New York City Department of
media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, Health and Mental Hygiene,
and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising Long Island City, NY, USA
approach towards advancing health equity and improving population health. (Z D Bailey ScD, N Linos ScD,
M T Bassett MD); Department
of Social and Behavioral
Introduction view—one that identifies and seeks to alter how such Sciences, Harvard T.H. Chan
Racial and ethnic inequalities, including health racism contributes to poor health—is required to School of Public Health,
inequities, are well documented in the USA (table),1–5 and understand, prevent, and address the harms related to Boston, MA, USA
have been a part of government statistics since the structural racism. There is a rich social science literature (Prof N Krieger PhD,
M Agénor ScD); and Bard Prison
founding of colonial America.6–8 However, controversies conceptualising structural racism,8–10,19 but this research Initiative, Annandale-on-
abound over explanations for these inequities.6–8 In this has not been adequately integrated into medical and Hudson, NY, USA
report, we offer a perspective not often found in the scientific literature geared towards clinicians and other (J Graves MPH)
medical literature or taught to students of health health professionals.9,10,12,13 In this report, we examine Correspondence to:
sciences, by focusing on structural racism (panel 1)9–11 as what constitutes structural racism, explore evidence of Dr Mary T Bassett,
42-09 28th Street, Long Island
a key determinant of population health.9,10,12,13 To explore how it harms health, and provide examples of City, NY 11101, USA
this determinant of health and health equity, we examine interventions that can reduce its impact. Our central mbassett@health.nyc.gov
a range of disciplines and sectors, including but not argument is that a focus on structural racism is essential See Online for infographic
limited to medicine, public health, housing, and human to advance health equity and improve population health. www.thelancet.com/
resources. Our focus is the USA. infographics/us-health

Although there is growing interest in understanding Structural racism: a brief introduction

how social factors drive poor health outcomes,14 and
directed investigation in social science and social
epidemiology into the interconnected systems of
discrimination,9,10,12,13 many academics, policy makers,
scientists, elected officials, and others responsible for
defining and responding to the public discourse remain
resistant to identify racism as a root cause of racial health
inequities.9,10,13 For example, in a Web of Science search
done on Sept 7, 2016, with the term “race” in conjunction
with “health”, “disease”, “medicine”, or “public health”,
47 855 articles were retrieved. However, when “race” was
replaced by “racial discrimination”, only 2061 articles
were located, and only 1996 articles were found when it
was replaced by “racism”. Furthermore, when “race” was
replaced by “structural or systematic racism”, only
195 articles were identified (ie, 0·4% of those identified
with the search term “race”).
To date, the small body of empirical research on racial
discrimination and health has focused primarily on the
stress of perceived unfair treatment as experienced
by individuals (interpersonal racism).9,10,12,15–18 Such
inequitable suffering matters, but a broad, societal
Any account of structural racism within the USA must start
with the experiences of black people and the Indigenous
people of North America. It was on these two groups that
the initial colonisers of North America (the English, French,
Search strategy and selection criteria
An overarching search strategy was not used; instead, we
drew on our collective experience and specific searches for
different sections to update or amplify the completeness of
our review of the published literature. To identify review
articles on racism and health, we searched Web of Science,
PubMed, and Google Scholar using the search terms “racism
AND health” or “racial discrimination AND health” or
“structural racism AND health”. Only review articles
published in English between Jan 1, 2000, and Feb 23, 2016,
were considered. We identified additional sources by
performing selected searches in the databases listed above
and the Google and DuckDuckGo search engines. These
searches were further supplemented from our own
knowledge of this subject.

www.thelancet.com Vol 389 April 8, 2017 1453

 Series
Key messages
• Racial/ethnic health inequities in the USA are well documented, but controversies over
explanations of these inequities persist.
• To date, in the small body of empirical research on racism and health, most studies
have focused on interpersonal racial/ethnic discrimination, with comparatively less
emphasis on investigating the health effects of structural racism.
• Structural racism involves interconnected institutions, whose linkages are historically
rooted and culturally reinforced. It refers to the totality of ways in which societies
foster racial discrimination, through mutually reinforcing inequitable systems
(in housing, education, employment, earnings, benefits, credit, media, health care,
criminal justice, and so on) that in turn reinforce discriminatory beliefs, values, and
distribution of resources, which together affect the risk of adverse health outcomes.
• One example of structural racism pertains to the ongoing residential segregation of black
Americans, which is associated with adverse birth outcomes, increased exposure to air
pollutants, decreased longevity, increased risk of chronic disease, and increased rates of
homicide and other crime. Residential segregation also systematically shapes health-care
access, utilisation, and quality at the neighbourhood, health-care system, provider, and
individual levels.
• Several avenues exist for potentially efficacious solutions, including the use of a
focused external force that acts on multiple sectors at once (eg, place-based
multisector initiatives such as Purpose Built Communities, Promise Neighborhoods,
and Choice Neighborhoods), disruption of leverage points within a sector that might
have ripple effects in the system (eg, reforming drug policy and reducing excessive
incarceration), and divorcing institutions from the racial discrimination system
(eg, by training the next generation of health professionals about structural racism).
• A focus on structural racism offers a concrete, feasible, and promising approach towards
advancing health equity and improving population health. Without a vision of health
equity and the commitment to tackle structural racism, health inequities will persist.
Dutch, and Spanish) first promulgated genocide and
enslavement, and created both legal and tacit systems of
racial oppression.8,20,21 Our report focuses primarily on the
experiences of black Americans, since most research on
racism and health has focused on this racialised group. We
recognise, however, that Native Americans and other people
of colour in the USA—including Latinos, Asian Americans,
and Pacific Islanders—have also been the target of health-
harming racial discrimination, combined with anti-
immigrant and religious (eg, anti-Muslim) discrimination.8
Although issues of immigration and nativism are beyond
the scope of this report, our analysis is applicable to the
structural discrimination experienced not only by these
groups but also by societally defined and racialised groups
in other countries with systems of oppression that have led
to health inequities.9,14,16,22
Racial ideology and the categorisation of racialised
social groups
As with many other race-conscious societies, the USA has a
long history as a slaveholding republic and as a colonial-
settler nation.8,19–21 The modern concept of “race” emerged at
the cusp of the country’s nationhood, as early European
settlers sought to preserve an economy largely on the basis
of the labour of enslaved African people and their
descendants while upholding the universal rights of
1454 www.thelancet.com Vol 389 April 8, 2017
“man”.6,8,19,23,24 To reconcile this contradiction, the colonists
established legal categories based on the premise that black
and Native American individuals were different, less than
human, and innately, intellectually, and morally inferior—
and therefore subordinate—to white individuals.8,19–21,23
Buttressing this concept of racial classification has been a
long legacy of now discredited scientific theory and inquiry,
constructed around the primary assumption that “race”
was an innate and fixed characteristic and an inherently
hierarchical category.6,8,9,19,23 This manufactured concept of
race used ostensibly visible phenotypic characteristics and
ancestry to justify systems of oppression and privilege.6,8,19
Similar processes in other racialised societies, such as
those of South Africa and Brazil, have produced country-
specific racial hierarchies, which ascribe human value on
the basis of proximity to whiteness.22 Furthermore, since
the 18th century, scientific racism rooted in Aryan or white
supremacy became a blueprint for many other mani­
festations of society-specific scientific racism around the
world.6,22,25
The continuing role of ostensibly colour-blind laws and
policies
In the USA, since the passage of the 1960s civil rights
laws,8,20 government complicity in the promotion of racial
discrimination is typically viewed as belonging to the
past. Examples of such de jure discrimination include
the legalisation and enforcement of slavery, the Jim Crow
laws enacted in the 1870s (which legalised racial
discrimination in reaction to the civil rights and social
gains attained by the newly freed black population in the
short Reconstruction period after the US Civil War), the
forcible removal of Indigenous people from their lands,
and the forcible transfer of Indigenous children from
their families to punitive so-called boarding schools
designed to strip them of their culture.8,19–21,26,27
However, this standard view overlooks the long reach of
past practices and the impact of contemporary practices of
institutional racism in both the public and private sector;
such practices have been and continue to be realised by
purportedly colour-blind policies that do not explicitly
mention “race” but bear racist intent or consequences, or
both.28–30 Institutional racism in one sector reinforces it in
other sectors, forming a large, interconnected system of
structural racism whereby unfair discriminatory practices
and inequities in the health and criminal justice systems
and in labour and housing markets bolster unfair
discriminatory practices and inequities in the educational
system, and vice versa.10 One key example, with ongoing
intergenerational effects, is the historic Social Security Act
of 1935, which created an important system of
employment-based old-age insurance and unemployment
compensation.8,20 The Act also, however, deliberately
excluded agricultural workers and domestic servants—
occupations largely held by black men and women. This
accommodation was made to secure the votes of
Democrats in the South and thus ensure passage of the
 Series

Total White non-Hispanic Asian* Hispanic or Black non- Native American

Latino Hispanic† or Alaska Native
Wealth: median household assets (2011) $68 828 $110 500 $89 339 $7683 $6314 NR
Poverty: proportion living below poverty level, all ages 14·8%; 21·0% 10·1%; 12·0% 12·0%; 12·0% 23·6%; 32·0% 26·2%; 38·0% 28·3%; 35·0%
(2014); children <18 years (2014)
Unemployment rate (2014) 6·2% 5·3% 5·0% 7·4% 11·3% 11·3%
Incarceration: male inmates per 100 000 (2008) 982 610 185 836 3611 1573
Proportion with no health insurance, age <65 years (2014) 13·3% 13·3% 10·8% 25·5% 13·7% 28·3%
Infant mortality per 1000 livebirths (2013) 6·0 5·1 4·1 5·0 10·8 7·6
Self-assessed health status (age-adjusted): proportion with 8·9% 8·3% 7·3% 12·2% 13·6% 14·1%
fair or poor health (2014)
Potential life lost: person-years per 100 000 before the age 6621·1 6659·4 2954·4 4676·8 9490·6 6954·0
of 75 years (2014)
Proportion reporting serious psychological distress‡ in the 3·4% 3·4% 3·5% 1·9% 4·5% 5·4%
past 30 days, age ≥18 years, age-adjusted (2013–14)
Life expectancy at birth (2014), years 78·8 79·0 NR 81·8 75·6 NR
Diabetes-related mortality: age-adjusted mortality per 20·9 19·3 15·0 25·1 37·3 31·3
100 000 (2014)
Mortality related to heart disease: age-adjusted mortality 167·0 165·9 86·1 116·0 206·3 119·1
per 100 000 (2014)

NR=not reported. *Economic data and data on self-reported health and psychological distress are for Asians only; all other health data reported combine Asians and Pacific Islanders. †Wealth, poverty, and
potential life lost before the age of 75 years are reported for the black population only; all other data are for the black non-Hispanic population. ‡Serious psychological distress in the past 30 days among adults
aged 18 years and older is measured using the Kessler 6 scale (range=0–24; serious psychological distress: ≥13). Sources: wealth data taken from the US Census;1 poverty data for adults taken from the National
Center for Health Statistics,2 and poverty data for children taken from the National Center for Education Statistics;3 unemployment data taken from the US Bureau of Labor Statistics;4 incarceration data taken
from the Kaiser Family Foundation;5 data on uninsured individuals taken from the National Center for Health Statistics;2 data on infant mortality, self-assessed health status, potential life lost, serious
psychological distress, life expectancy, diabetes-related mortality, and mortality related to heart disease taken from the National Center for Health Statistics.2

Table: Social and health inequities in the USA

Act. This racially motivated exclusion afforded the

primarily white recipients additional opportunities to
acquire wealth and pass it on to their children, while those
excluded were unable to do so and instead often became
dependent on their children after retirement, thereby
further curtailing the intergenerational accumulation of
assets.8,20 The net result has been an entrenchment of
racial economic inequities that persist to this day.8,10,20,29,30
Another example is the War on Drugs and tough-on-
crime policies enacted in the 1970s and 1980s (labelled
“The new Jim Crow”).28 Without ever referring to “race” by
itself, these policies stereotyped black Americans as drug
addicts—despite similar prevalence of illicit drug use
among white Americans—and disproportionately targeted
black people for incarceration.28,30 The legacy of these
policies is that the annual rate of incarceration of black
men is 3·8–10·5 times greater than that of white men,
across all age groups;31 moreover, in 2014, almost 3% of all
black men in the USA were serving sentences of at least
1 year in prison.31
Panel 1: Definitions of structural racism and institutional racism
Many academics use structural racism and institutional racism interchangeably, but we
consider these terms as two separate concepts.
Structural racism refers to “the totality of ways in which societies foster [racial]
discrimination, via mutually reinforcing [inequitable] systems…(eg, in housing,
education, employment, earnings, benefits, credit, media, health care, criminal justice,
etc) that in turn reinforce discriminatory beliefs, values, and distribution of resources”,
reflected in history, culture, and interconnected institutions.9 This definition is similar to
the “über discrimination” described by Reskin.10
Within this comprehensive definition, institutional racism refers specifically to racially
adverse “discriminatory policies and practices carried out…[within and between
individual] state or non-state institutions” on the basis of racialised group membership.9
Some of these institutional policies and practices explicitly name race (eg, de jure Jim
Crow laws, which required schools and medical facilities to be racially segregated, and
restricted certain neighbourhoods to be white-only), but many do not (eg, employer
practices of screening applications on seemingly neutral codes, such as telephone area
codes or ZIP codes, because of presumptions about which racial groups live where).11

Structural racism in the private sector
Institutional racism also continues unabated in the
private sector, especially in housing and employment,
underpinning the structural racism of the ostensibly
colour-blind policies in the public sector.32–34 In their
review of the evidence on discrimination in four domains
(employment, housing, credit markets, and consumer
markets), Pager and Shepherd33 argue that discrimination
in the rental and housing markets against black and
Latino communities remains pervasive, even though
intentional redlining is no longer legal (the term
redlining is derived from the legal practice initiated in
1934 by the Federal Housing Administration, which
involved marking maps with red lines to delineate
neighbourhoods where mortgages were denied to
marginalised, racialised groups to steer them away from

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Panel 2: Pathways between racism and health9,12,13,16–18
Economic injustice and social deprivation8,9,12,32–35
Examples include residential, educational, and occupational segregation of marginalised,
racialised groups to low-quality neighbourhoods, schools, and jobs (both historical
de jure discrimination and contemporary de facto discrimination), reduced salary for the
same work, and reduced rates of promotion despite similar performance evaluations
Environmental and occupational health inequities9,36–38
Examples include strategic placement of bus garages and toxic waste sites in or close to
neighbourhoods where marginalised, racialised groups predominantly reside, selective
government failure to prevent lead leaching into drinking water (as in Flint, MI, in 2015–16),
and disproportionate exposure of workers of colour to occupational hazards
Psychosocial trauma9,15,16,18
Examples include interpersonal racial discrimination, micro-aggressions (small, often
unintentional racial slights and insults, such as a judge asking a black defence attorney
“Can you wait outside until your attorney gets here?”), and exposure to racist media
coverage, including social media
Targeted marketing of health-harming substances9,30,39
Examples include legal substances such as cigarettes and sugar-sweetened beverages, and
illegal substances such as heroin and illicit opioids
Inadequate health care9,17,40–45
Examples include inadequate access to health insurance and health-care facilities, and
substandard medical treatment due to implicit or explicit racial bias or discrimination
State-sanctioned violence and alienation from property and traditional lands9,21,30,46–48
Examples include police violence, forced so-called urban renewal (the use of eminent
domain to force the relocation of urban communities of colour), and the genocide and
forced removal of Native Americans
Political exclusion49,50
Examples include voter restrictions (eg, for former felons and through identification
requirements)
Maladaptive coping behaviours9,16,18
Examples include increased tobacco and alcohol consumption on the part of
marginalised, racialised groups
Stereotype threats 15–18
Examples include stigma of inferiority, leading to physiological arousal, and an impaired
patient–provider relationship
white neighbourhoods). Additionally, strong evidence
from experimental audit studies reveals continued racial
discrimination in hiring decisions. In one study that
used identical résumés, which differed only in the name
of the applicant, hiring managers called back those with
traditionally white names (eg, Brad or Emily) 50% more
often than those with traditionally black names (eg,
Jamal or Lakisha).33 In another study that used mailed
résumés, white applicants with criminal records were
called back more often than were black applicants
without criminal records.33 Ongoing de facto racial
segregation in the workforce is partly why black
Americans, on average, have lower wages than those of
white Americans.35
1456 www.thelancet.com Vol 389 April 8, 2017
As this brief summary suggests, structural racism is an
ongoing—and not just historical—concern across
multiple systems. We next consider the implications of
such systemic racism on population health.
Health consequences of structural racism:
evidence and evidence gaps
Contemporary scholarship has established multiple
pathways by which racism harms health, involving
adverse physical, social, and economic exposures, as well
as maladaptive coping behaviours and stereotype threats
(panel 2).9,12,13,15–18,21,30,32–50 Typically concurrent, these
exposures can accumulate over the life course and across
generations.
To date, research on racial discrimination and health
has focused primarily on interpersonal discrimination as
a psychosocial stressor.9,16–18 The strongest evidence in the
scientific literature is for adverse effects on psychological
wellbeing, mental health, and related health practices
(eg, sleep disturbance, eating patterns, and the
consumption of psychoactive substances, including
cigarettes, alcohol, and drugs), as summarised in
panel 3.9,12,15,16,18,35,51–58 Furthermore, growing research is
linking interpersonal racism to various biomarkers of
disease and wellbeing, including allostatic load,
inflammatory markers, and hormonal dysregulation.16,18
Here, we focus instead on adverse health effects of
structural racism through two distinct but related pathways
emphasised in the literature: residential segregation and
health-care quality and access.9,12,13,18 Both of these
pathways include actionable leverage points to reduce
exposure and promote health equity. A third relevant
pathway, discriminatory incarceration,28,30,35 is only briefly
mentioned since it is discussed elsewhere in this Series
by Wildeman and Wang.59
Residential segregation
As a reflection and reinforcement of structural and
institutional racism, most residents in the USA have
grown up in, and continue to live in, racialised and
economically segregated neighbourhoods.29,33,34,60 Analysis
of 2010 US Census data has found that “the average
white person in metropolitan America lives in a
neighborhood that is 75% white”, whereas “a typical
African American lives in a neighborhood that is only
35% white (not much different from 1940) and as much
as 45% black”.61 The literature on racial residential
segregation and poor health32,34,36,37,62–68 examines several
direct and indirect pathways through which structural
racism harms health, including the high concentration
of dilapidated housing in neighbourhoods that people of
colour reside in,62,63 the substandard quality of the social64
and built65 environment, exposure to pollutants and
toxins,36,37,65 limited opportunities for high-quality
education and decent employment,34,66 and restricted
access to quality health care.65 Health outcomes
associated with residential segregation documented
 Series

Panel 3: Dominant approaches to studying racial discrimination as a psychosocial stressor and associated adverse health
outcomes, with counterexamples of research on measures of structural racism
Racism and stress metabolism change in response to chronic stressors.15 There is
To date, racism has primarily been conceptualised as a burgeoning evidence linking experiences of discrimination to
psychosocial stressor in the health science literature, and the biomarkers of disease and wellbeing, including allostatic load,
strongest and most consistent evidence of its adverse health telomere length, cortisol dysregulation, and inflammatory
effects concerns mental health, as detailed in several markers.9,16,18
comprehensive, systematic reviews.9,12,15,16,18 In one such review,16
Reliance on self-reports of exposure to racial discrimination
published in 2015, the authors found that self-reported racism
Most of the research on racial discrimination and health has
was positively associated with increased levels of negative
relied on self-reported measures, although some studies have
mental health, including all individual mental health outcomes
used vignettes or experimental situations. Evidence suggests
except for positive affect (eg, depression, anxiety, distress,
that because of well known cognitive biases, including social
psychological stress, negative affect, and post-traumatic stress),
desirability, self-reported data are likely to provide an
and negatively associated with positive mental health (eg,
underestimate of actual exposure, leading to underestimates of
self-esteem, life satisfaction, control and mastery, and
the magnitude of the association of racial discrimination with,
wellbeing). After adjusting for publication bias, the association
and its impact on, adverse health outcomes.9,18 Some immigrant
between reported racism and mental health remained twice as
groups, moreover, might be less likely than others to recognise
large as that for physical health, which was driven primarily by
racist interactions, or less likely to attribute discriminatory
obesity outcomes. There is growing evidence that experiences
behaviour to racism as opposed to language skills, immigration
of racism are associated with poor sleep outcomes, which could
status, or chance.9,52
be linked to both mental and physical health.51
Counterexamples of research on measures of structural racism
Stress pathways
Although small in comparison with psychosocial approaches,
Much of the research on interpersonal racism and health has
an emerging body of research has begun to investigate the
posited that racism is a social stressor that operates through
relationship between health and four domains of state-level
diverse stress pathways, including physiological, psychological,
structural racism: political participation, employment and job
and behavioural pathways. Experiences that are perceived as
status, educational attainment, and judicial treatment,
racist act as social stressors, which can initiate a set of
including incarceration.9,12,16,35,53–58 Black people living in states
neurobiological and behavioural responses (ie, coping
with higher levels of structural racism in these domains were
behaviours) that can affect mental and physical health. These
more likely than those living in states with lower levels of
experiences can be chronic and include everyday hassles of
structural racism to self-report a myocardial infarction in the
receiving poor service at restaurants, being followed or not
previous year; meanwhile, the same association for white
helped in stores, and generally being treated with less respect
people was null or protective.57Another study that used the
and consideration than others. Acute experiences of violence,
same measures found a positive association between structural
harassment, and other threatening behaviour are also included
racism at the state level and the odds of births that were small
in this category. However, although such exposures are most
for gestational age in both black and white women.58 Such
likely to garner media attention, the common, chronic
measures could be used to build the evidence base regarding
experiences of discrimination are more consistently associated
the connections between structural and institutional racism
with poor health outcomes than are acute experiences,9,15,16,18
and health, and highlight areas for intervention. Priority should
probably reflecting how brain chemistry and general
be given to expanding this type of research.

among black Americans include adverse birth
outcomes,32 increased exposure to air pollutants,36
decreased longevity,34,66 increased risk of chronic
disease,32,34,64 and increased rates of homicide and other
crime.66,67 These adverse outcomes far outweigh any
benefits deriving from social support or political power
that accrue from the clustering of black Americans (or
other oppressed racialised groups) in adjoining
neighbourhoods.63,68 Residential segregation is thus a
foundation of structural racism and contributes to
racialised health inequities.
Moreover, analysis of residential segregation requires
addressing the intertwined occurrences of residential
segregation by both racialised group and class.60,69,70 In the
USA there has been a shift from macrosegregation to
microsegregation, whereby “blacks and whites became
more evenly distributed across states and counties during
the first two-thirds of the twentieth century, [and] … less
evenly distributed at the city and neighborhood levels”.60
Highlighting the need to think about smaller geographies,
researchers have also noted that, as income inequality has
increased, people at the top and bottom of the
socioeconomic distribution have increasingly become
spatially isolated,69,70 such that “middle-class blacks are less
able than their white counterparts to translate their higher
economic status into desirable residential conditions”.34
In recognition of the trend towards microsegregation
and increased social polarisation, public health

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 Series
researchers have recently begun to use the Index of
Concentration at the Extremes (ICE).70 This measure was
introduced into the sociological literature in 200169 and
was designed to measure economic polarisation—the
extent to which a population is concentrated into the
extremes of wealth or impoverishment—by taking the
difference between the number of affluent and poor
households in an area and dividing it by the total number
of households in the area.70 Moreover, these areas can be
measured at multiple levels (eg, census tract, city
neighbourhood, and county). New innovations include
the development of an ICE for racialised economic
segregation, which uses data on the joint distribution of
income and race/ethnicity. Research done in New York
City, for example, has shown that ICE measures that
captured both income and racialised group yielded larger
risk ratios, at both the neighbourhood and census tract
levels, for infant mortality, premature mortality, and
diabetes mortality than an ICE solely for income or the
poverty level.70
Underscoring the need for explicit analysis of the
health burden of residential segregation (regardless of
how it is measured) and neighbourhood disinvestment,
there is evidence to suggest that these structurally driven,
place-based exposures harm economic opportunity and,
when coupled with inadequate gun control, contribute to
the lethal burden of gun violence and crime in
predominantly black and Latino neighbourhoods71,72 and
in impoverished Native American reservations.21 In turn,
the violence and crime in these neighbourhoods
reinforces the intergenerational legacy of racialised
punitive policing,8,20,21,28,31 perpetuating vicious cycles of
further community depletion and adverse health
outcomes.8,9,28,30,31,35,59
Discriminatory incarceration
The penal institutions that constitute the US criminal
justice system—police departments, court systems,
correctional agencies, parole and probation departments,
and sentencing boards—have established policies and
practices that are ostensibly colour-blind yet they
criminalise communities of colour (eg, through day-to-
day practices such as stop and frisk) and disproportionately
incarcerate black men, women, and children.30 As
reviewed in this Series by Wildeman and Wang,59 each
component of the criminal justice continuum—from
arrest to re-entry—carries various health consequences,
and a growing body of literature has documented severe
adverse health outcomes associated with incarceration
on the individual, their families, and neighbourhoods.
What should not be lost in the explication of these
outcomes is their roots in structural racism; the present
disproportionate representation of black people in the
penal system is reminiscent of the Black Codes and
convict leasing practices from the colonial period.8,26 New
freedoms afforded to black people following the US Civil
War were promptly undone by laws that selectively
1458 www.thelancet.com Vol 389 April 8, 2017
criminalised unemployment, vagrancy, and loitering.26
The resultant prison population effectively re-established
free labour for Southern states to rebuild infrastructure.73
The effects of mass incarceration, as traced by Wildeman
and Wang59 from the 1970s, are best understood as a
continuation of racialised imprisonment8,10,20 rather than
as an emergent process.28 Moreover, as noted previously,
strong feedback mechanisms exist between inequities in
incarceration, employment, and health on a population
level.30,35,59
Health-care quality and access
Interpersonal racism, bias, and discrimination in health-
care settings can directly affect health through poor
health care. Almost 15 years ago, the Institute of Medicine
Report titled Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care40 documented systematic
and pervasive bias in the treatment of people of colour,
resulting in substandard care. Evidence continues to
support this finding.41–44
However, it would be short sighted to view these
problems solely as a matter of institutional and
interpersonal discrimination within health-care
settings.17,40–44 Instead, it is essential to understand the
broad context within which health-care systems operate,
including the potentially disparate settings in which
health-care professionals and their patients reside.
Specifically, residential segregation systematically shapes
health-care access, utilisation, and quality at the
neighbourhood, health-care system, provider, and
individual levels.45 The socioeconomic disadvantage
resulting from systematic disinvestment in public and
private sectors renders it difficult to attract primary-care
providers and specialists to predominantly black
neighbourhoods.40,45 Likewise, health-promoting resources
are inadequately invested into these neighbourhoods.
Health-care infrastructure and services are inequitably
distributed, resulting in predominantly black neighbour​
hoods having lower-quality facilities with fewer clinicians
than those in other neighbourhoods. Moreover, most of
these clinicians have lower clinical and educational
qualifications than those in other neighbourhoods. This
inequitable system is likely to disproportionately expose
black residents to racially biased services.45
Addressing structural racism to advance health
equity
Although efforts to counter institutional racism and
residential segregation in the housing market and
medical care system require initiatives focused on these
institutions, such initiatives are not sufficient. Also
needed is intersectoral work, especially that which is
guided by transdisciplinary frameworks and action.
Analytical insights derived from a systems perspective
suggest several avenues for efficacious solutions,
including the use of a focused external force that acts on
multiple subsystems (ie, sectors) at once, disruption of

leverage points (ie, key points of intervention within a
sector that could be important for maintenance of the
system, both within and outside the particular sector in
question), and divorcing institutions from the racial
discrimination system.10 We highlight some promising,
concrete, intersectoral examples of each of these types of
solutions, which have the potential to reduce, if not
remove, the burden of structural racism on population
health.
Place-based, multisector, equity-oriented initiatives
Health and health equity are substantially influenced by
the places where people live, work, play, and pray.14 Yet,
the USA has high levels of racialised economic
segregation.69,70 Within this context, multisector, place-
based partnerships focusing on equity can be an effective
means of placing pressure on the systems of structural
racism operating in a specific geographical region.
Place-based initiatives create structures for reinvesting in
neighbourhoods that have long been sidelined. Several
initiatives have combined public and private partners
from multiple sectors to achieve community-specific
changes.74 These community-specific, multisector
interventions that seek neighbourhood-wide coverage
have thus far focused primarily on predominantly black
and Latino neighbourhoods, and also on Native American
reservations, that have experienced high levels of poverty,
health-limiting built environments, and substandard
resources for schools and housing as a result of
generations of structural racism.
Established in 2009, Purpose Built Communities is
exploring the redevelopment of more than 20 high-need
neighbourhoods with the use of a model based on their
original 1995 development site: the East Lake
neighbourhood of Atlanta, GA.74 About 20 years ago, a
private philanthropist partnered with the president of the
Atlanta Housing Authority, a resident leader, and several
community business leaders to revitalise the area by
razing a violent, poorly maintained public housing
development and rebuilding a new mixed-income
development, which involved temporary displacement of
residents during construction. Unlike other attempts at
rebuilding public housing, this development’s planning
and rollout was organised and backed by a dedicated
non-profit and focused on high-quality construction and
on safe walkways and streets. The effort included a
cradle-to-college educational curriculum, and a
combination of facilities, programmes, and services
prioritised by community residents to promote healthy
behaviours, create jobs, and reduce crime in the short
term, and break the cycle of intergenerational poverty
concentrated in this community in the long term.74
With active involvement of community residents, by
2015, crime had declined by 95% (compared with a
50% overall decline in Atlanta), the employment rate
among families in public housing increased from 13%
to 70%, capital investments increased from no
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Series
investment (over the course of 30 years before the
project) to US$123 million, property values in the
surrounding area increased, and new grocery stores,
banks, and other businesses opened.74 The evidence of
changes in the social determinants related to health
inequities is striking; to date, no health impact
assessment has been done, although it is clearly
warranted. Future place-based interventions should
build in health equity impact assessments from the
start. Two federal initiatives launched in 2010 have
followed similar principles: the US Department of
Education’s Promise Neighborhood initiative and the For more on Promise
US Department of Housing and Urban Development’s Neighhorhoods see
https://www2.ed.gov/programs/
Choice Neighborhood initiative. Results of health impact promiseneighborhoods/index.
assessments are eagerly awaited. html
Short of full-scale community redevelopment, data For more on Choice
suggest that improvements in housing lead to Neighborhoods see
improvements in health. In New York City, individuals https://portal.hud.gov/
hudportal/HUD?src=/program_
and families on a low income are able to enter lotteries offices/public_indian_housing/
for affordable housing units. Data from the New York programs/ph/cn
City Housing and Neighborhood Study,75 which assessed
the impact of re-housing on those who won the lottery
compared with those who did not, showed reductions in
depression and asthma exacerbations. Although results
among adolescents were mixed, findings from the
Moving to Opportunity study,76,77 in which vouchers for
housing were randomly allocated, suggest that housing
mobility policies that enable voluntary movement out of
deprived neighbourhoods can result in long-term
improvements in health and social outcomes.
Building government and public support for large-
scale initiatives to counter structural racism is both
necessary and possible. In May, 2016, the Government
Alliance for Race and Equity (GARE) and the non-profit
Living Cities jointly launched Racial Equity Here, a
$3 million initiative to help five cities (Albuquerque, NM,
Austin, TX, Grand Rapids, MI, Louisville, KY, and
Philadelphia, PA) improve racial equity, building on
approaches such as Seattle’s Race and Social Justice For more on Seattle’s Race and
Initiative, which has explicitly recognised the links Social Justice Initiative see
http://www.seattle.gov/rsji
between racial equity and health equity.78 As the Mayor of
Austin, Steve Adler, noted, “Government helped create a
lot of the inequities, it institutionalized them. It’s
important for the government, the city government to
address racial inequity, not just because of the conditions,
but also because we helped create it.”78
Advocating for policy reform
With the recognition that mass incarceration is a system
used to subordinate black people,10,28,30 efforts to reduce
discriminatory criminal sanctions on drug use (a leverage
point) are also beginning to gain traction. From the 1980s
to 2010, the federal government sentencing guidelines
mandated penalties for crimes related to crack cocaine
(a cheaper formulation more common in black
communities than in other communities) that were
100 times harsher than sentences for crimes involving
 Series
the pharmacologically identical substance in powder
form, effectively targeting black people for prolonged
prison sentences.30 In the first sentencing breakthrough
in decades—the Fair Sentencing Act of 2010—the crack-
to-powder penalty ratio was reduced to 18:1, shrinking
the disparity but not eliminating it.30 Meanwhile,
prescription opioids, which are fuelling the current
opioid epidemic among white people, have been relatively
unregulated. It was not until opioid addicts from white
communities started being incarcerated and dying in
large numbers that the national narrative shifted from
penalisation to treatment—a clear demonstration of the
racialised nature of the War on Drugs.79
The past decade has also witnessed new bipartisan
efforts, across the country, to reduce the number of
people who are imprisoned. For example, California has
sought to address its unconstitutionally overcrowded
prisons through several legislative initiatives, including
Proposition 47.80 This ballot initiative, passed in
November, 2014, commutes drug possession felonies
(and a few minor offenses) to misdemeanours. It also
allows people serving a sentence for an eligible felony
conviction to petition the court for resentencing. With
the disproportionate impact of drug arrests, prosecutions,
and convictions on black and Latino men and women,
Proposition 47 is likely to reduce racial inequities in
sentencing. Since 2014, more than 4000 people have been
released under this initiative and California has reduced
overcrowding in prisons; however, racial inequities and
health effects have not yet been assessed.81
Training the next generation of health professionals
Structural racism has developed over centuries and is
deeply embedded in the thoughts and behaviours of people
in the USA and other countries,6,8,10,22,25 with its influence
extending to how health sciences are taught and the
routine practices of health agencies and health-care
providers.6,7,13,82–85 An analysis of structural racism is
required to recognise these problems and change them.
Fortunately, a new wave of public health and medical
students, galvanised by protests over police killings and
the Black Lives Matter movement, have been advocating to
ensure that medical and public health schools incorporate
essential pedagogy about racism and health into standard
coursework, as one step towards divorcing medical and
public health institutions from their supportive roles in the
system of structural racism.13,82–84,86 Similarly, several public
health agencies have begun to reform their institutional
structure and organisational culture.
The standard practice for teaching about race and
health in medical and public health schools is one in
which race is often discussed, but conversations about
racism are sidelined, with scant hours (if any) devoted to
social epidemiologists, medical anthropologists, social
scientists, or historians who focus on racism and
health.82–84 Few scientific and medical textbooks include
discussions of how racism affects the conceptualisation
1460 www.thelancet.com Vol 389 April 8, 2017
of race or an analysis of racial inequality in relation to
health and other outcomes.85 Although many medical
schools now include diversity training and provide
instruction on cultural competency, such instruction is
often brief (and sometimes delivered online). Moreover,
the programmes typically focus on individual
responsibility to counteract interpersonal discrimination;
the goal is for individuals to increase their sensitivity to,
and knowledge about, other racial/ethnic groups.87,88 The
emphasis is therefore on “others”, in a way that could
inadvertently contribute to racial stereotyping, as opposed
to critical self-reflection about the participants’ positions
in their societies’ race relations.
By contrast, approaches based on structural
competency,83 cultural humility,89 and cultural safety46,90,91—
which have been implemented in health professionals’
training in several countries such as Canada and New
Zealand—encourage a lifelong commitment to self-
reflection and mutual exchange in engaging power
imbalances along the lines of cultural differences. These
approaches emphasise the value of gaining knowledge
about structural racism, internalised scripts of racial
superiority and inferiority, and the cultural and power
contexts of health professionals and their patients or
clients. Tying interactions between patients and health-
care providers to population-level inequalities requires
skilled instruction and considerable time, far beyond that
patched together for short training courses in cultural
competency.83 These approaches also require that health
professionals be informed by scholarship from diverse
disciplines about the origins and perpetuation of—as well
as remedies to counter—structural racism. It remains the
charge of those committed to exploring and reversing
structural racism to connect how these forms of social
inequality translate into health and health-care inequities,
within and across generations.9,13,82,86
Professional education about structural racism after
graduate school also matters, especially for clinical and
public health practitioners whose decisions affect peoples’
health daily.13,92 As Hardeman and colleagues13 advocate,
health professionals already practising in the field can
still “learn, understand, and accept” the contemporary
and historical basis of structural racism in the USA,
understand how structural racism shapes our overarching
narrative around inequities, define and call out racism
when it is present, and contribute to the understanding of
equity through clinical care and health research from the
perspective of marginalised groups and with a healthy
dose of cultural humility. Several local health departments
have already incorporated anti-racism training into staff
professional development, and introduced internal
reforms to drive organisational change.92,93 For example,
in the mid-1990s the Alameda County Public Health
Department began to place neighbourhood offices in
areas with poor health outcomes. Over time, these offices
drove changes in the department, including additional
community involvement, staff trainings on anti-racism, a

new unit and a strategic plan to incorporate equity into
their work, and an increased presence of the health
department in local activism.92 The Boston Public Health
Commission has also engaged in organisational change,
launching a Racial Justice and Health Equity Initiative
that incorporates an anti-racism advisory committee, the
development of a health equity framework, anti-racism
training and professional development, and a forthcoming
evaluation of its activities.93 As institutional reform is
closely associated with other models of productive
practices—including quality improvement, collective
impact, community engagement, and community
mobilisation—application of an anti-racism lens should
not only be judged on its moral merits but also on its
contributions to organisational effectiveness. We
anticipate that forthcoming evidence will continue to
support the view that removing racism from institutions
is essential to protect and promote the health of our
increasingly diverse communities.
Conclusion
Since the American colonial period, public and private
institutions have reinforced each other, maintaining
racial hierarchies that have allowed white Americans,
across generations, to earn more and consolidate more
wealth than non-white Americans, and maintain political
dominance. This structural racism has had a substantial
role in shaping the distribution of social determinants of
health and the population health profile of the USA,
including persistent health inequities. The stark reality is
that research investigating the relationship between
structural racism and population health outcomes has
been scant, and even less work has been done to assess
the health impacts of the few interventions and policy
changes that could help dismantle structural racism.
We can, however, look to history as a guide. Notably,
the handful of studies on the impact of the abolition of
Jim Crow laws have consistently shown improvements in
mortality in the black community, and converging
mortality between black and white communities in the
15 years after the passage of the 1964 Civil Rights Act.53–56
We recognise that efforts to implement reforms to
dismantle structural racism have repeatedly encountered
serious obstacles and backlash from institutions,
communities, and individuals seeking to preserve their
racial privilege.8,20,26,30 However, as Frederick Douglass
famously said in his 1857 address on the struggle against
slavery in the USA, the West India emancipation, and the
backlash that ensued: “Power concedes nothing without
a demand.”94
Without a vision of health equity and the commitment
to tackle structural racism, health inequities will persist,
thwarting efforts to eliminate disparities and improve the
health of all groups—the overarching goals for US health
policy as enunciated by the official Healthy People 2020
objectives. The challenge is great, but rising to this
challenge lies at the heart of our mission and our
www.thelancet.com Vol 389 April 8, 2017 1461
Series
commitment, as health professionals, to prevent
avoidable suffering, care for those who are unwell, and
create conditions in which all can truly thrive.
Contributors
All authors contributed to the conceptualisation of the manuscript,
literature search, and writing of this report. ZDB, NK, and MTB took the
lead in ensuring coherence of the text, including the selection of
appropriate data, and in data interpretation.
Declaration of interests
We declare no competing interests.
Acknowledgments
NK’s work is supported in part by an American Cancer Society Clinical
Research Professor Award.
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 Series
Lancet 2017; 389: 1464–74
See Editorial page 1369
See Comment pages 1376
and 1378
This is the fourth in a Series of
five papers about equity and
equality in health in the USA
Department of Policy Analysis
and Management, Cornell
University, Ithaca, NY, USA
(C Wildeman PhD); Bureau of
Justice Statistics, Washington,
DC, USA (C Wildeman);
Rockwool Foundation Research
Unit, Copenhagen, Denmark
(C Wildeman); Yale School of
Medicine, New Haven, CT, USA
(E A Wang MD); and Bureau of
Justice Assistance, Washington,
DC, USA (E A Wang)
Correspondence to:
Dr Christopher Wildeman,
Department of Policy Analysis
and Management, Cornell
University, Ithaca, NY 14853,
USA
cjw279@cornell.edu
See Online for infographic
www.thelancet.com/
infographics/us-health
1464 www.thelancet.com Vol 389 April 8, 2017
America: Equity and Equality in Health 4
Mass incarceration, public health, and widening inequality
in the USA
Christopher Wildeman, Emily A Wang
In this Series paper, we examine how mass incarceration shapes inequality in health. The USA is the world leader in
incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be
imprisoned, and nearly half of black women currently have a family member or extended family member who is in
prison. However, until recently the public health implications of mass incarceration were unclear. Most research in
this area has focused on the health of current and former inmates, with findings suggesting that incarceration could
produce some short-term improvements in physical health during imprisonment but has profoundly harmful effects
on physical and mental health after release. The emerging literature on the family and community effects of mass
incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises
concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities
both in the USA and between the USA and other developed countries. Research into interventions, policies, and
practices that could mitigate the harms of incarceration and the post-incarceration period is urgently needed,
particularly studies using rigorous experimental or quasi-experimental designs.
Introduction of mass incarceration. According to sociologist
In this Series paper, we review research into the effects of David Garland,1 who first used a variant of the term mass
mass incarceration on health and health disparities incarceration, it entails historically and comparatively
within the USA and between the USA and other extreme levels of incarceration that are so heavily
developed democracies. We first outline the contours concentrated among some groups that incarceration has
Search strategy and selection criteria Key messages
We strove to achieve a complete search of peer-reviewed • In the USA, incarceration is common and concentrated in
articles and government-funded reports relating to the black community
incarceration and health. Because many of the journals that • Individuals who experience incarceration at any point in
publish research on family and community effects of mass their life are disproportionately in poor health both
incarceration are not indexed by PubMed or PsychInfo, we before, during, and after their incarceration
first did a Google Scholar search for peer-reviewed articles and • The physical health of individuals improves in some
government-funded reports, including a host of specific domains during incarceration, although the mental health
health conditions (such as hepatitis, cardiovascular disease, of individuals generally worsens
and major depressive disorder), in addition to the terms • Having been formerly incarcerated is associated with poor
“incarceration,” “imprisonment”, “jail”, and “prison” as our mental health and physical health outcomes, as well as
search terms. We then searched PubMed and PsychInfo using elevated mortality risk
the same terms. We did not use any date restrictions in our • Although little research considers the indirect health
search. We also searched the bibliographies of key peer- consequences of incarceration, having a family member
reviewed articles and relied on the few other review articles on incarcerated harms the mental and physical health of
the topic. Although our exploration was international in non-incarcerated female partners and children
scope, we restricted our search to articles and documents • High incarceration prevalence also compromises
published in English, with a focus on newer, innovative work. community health, with the strongest evidence
We cite the highest-quality works that have contributed the implicating community-level increased incidence of HIV
most to this burgeoning field, with special emphasis on • Mass incarceration contributes to racial health disparities in
studies using strong research designs making identification of the USA across a range of outcomes because of its direct and
plausibly causal relationships possible. Because the goal of our indirect consequences for health, and the disproportionate
Series paper was to consider the consequences of mass concentration of incarceration among black communities
incarceration for health disparities in the USA, we placed • Because the USA incarcerates many more of its citizens
substantially more emphasis on studies within the USA, than do other developed democracies, mass incarceration
although we also report research on prisoners’ health in other might have contributed to the country’s lagging
developed democracies when appropriate. performance on health indicators such as life expectancy
 Series

become a normal stage in the lifecourse. We then Mass incarceration

consider the health effects of current incarceration and On any given day, the USA incarcerates more of its
having ever been incarcerated, as well as health disparities citizens (2·2 million) and at a higher level (700 per
attributable to these effects. We next review data about the 100 000) than any other country. Yet, for much of its
broader health effects of mass incarceration, focusing on history, the USA was no outlier in terms of incarceration.
families, communities, states, and nations, as well as As in most developed democracies—the focus of all of
health disparities attributable to these effects. Finally, we our comparisons, because these countries are more
focus on the next steps for researchers, medical similar to the USA in key ways (such as general standard
professionals, and policy makers. Throughout, we are of living, political structure, and core population health
careful to note that the teasing out of causal relationships indicators such as infant mortality and life expectancy at
between incarceration and health outcomes on the basis birth) than some other counties (eg, China and Russia)
of existing research is difficult because there are no that have high incarceration prevalence—the US
randomised controlled trials of incarceration relative to incarceration prevalence hovered between 100 per
no incarceration in this research area. To overcome these 100 000 and 200 per 100 000 in the mid-20th century.7
obstacles to causal inference, we focus (when possible) on In 1950, for instance, the US incarceration prevalence
studies in which confounders were rigorously addressed was roughly 175 per 100 000,8 somewhat lower than
through various strategies, including natural experiments. Finland’s (185 per 100  000).9 This prevalence was
We find that incarceration is a pressing public health considerably increased for developed democracies, but
concern, affecting not only the health of currently and not an aberration.
formerly incarcerated individuals but also that of their Starting in the mid-1970s, the US incarceration
families and communities.2–4 Because of these myriad prevalence started to spiral upward (figure 1).5 By 1985,
negative consequences of mass incarceration for American the USA incarcerated 312 of every 100 000 residents.
society, we argue—consistent with some research in this 20 years later, the prevalence had risen to 743 per 100 000.
area5,6—that mass incarceration might partly account for Its closest competitors among developed nations were
widening health inequality both within the USA and New Zealand (173 per 100 000), Luxembourg (159 per
between the USA and other developed democracies. 100 000), and Spain (140 per 100 000).

Australia Austria Belgium Canada Denmark Finland France

800
Incarceration per 100 000

600

400

200

Germany Ireland Italy Japan Luxembourg Netherlands New Zealand

800
Incarceration per 100 000

600

400

200

Norway Portugal Spain Sweden Switzerland UK USA

800
Incarceration per 100 000

600

400

200

0
1980 1990 2000 1980 1990 2000 1980 1990 2000 1980 1990 2000 1980 1990 2000 1980 1990 2000 1980 1990 2000
Year Year Year Year Year Year Year

Figure 1: Trends in incarceration prevalence in 21 developed democracies, 1981–2007

Calculations based on data from Wildeman (2016).5

www.thelancet.com Vol 389 April 8, 2017 1465

 Series

Men born 1945–49, risk of imprisonment Men born 1965–69, risk of imprisonment undoubtedly helped to both launch mass incarceration
70 White and keep it going.10,11
60 Black Disparities in incarceration by race or ethnicity and
Risk of imprsonment (%)

50 education in the USA are marked and have been since the
40 earliest statistics were collected.10,12 Incarceration has
30 become common for poor men from ethnic minorities.13,14
20 2·8% of (non-Hispanic) white men born in the late 1960s
10 and 20·3% of (non-Hispanic) black men from the same
0 cohort spent time in prison by their 30s (figure 2).15,16 For
black men who did not complete high school, this risk
Children born 1978, risk of paternal imprisonment Children born 1990, risk of paternal imprisonment was 57·0%. Moreover, these figures in fact underestimate
70 White
Risk of paternal imprsonment (%)

the number of men who have experienced incarceration,

60 Black
because the data refer only to incarceration in prisons
50
(facilities run by the state or the federal government that
40
hold inmates with sentences in excess of 1 year) and
30
exclude incarcerations in jails (local facilities that hold
20 inmates awaiting trial or sentenced to less than 1 year),
10 which are far more common. No data are available for the
0 cumulative risk of total incarceration (in prisons and jails)
Total High school dropout Total High school dropout
because accurate estimates of the cumulative risk of ever
Figure 2: Risk of ever experiencing imprisonment by age 30–34 years for US men by birth cohort, and risk of experiencing jail incarceration in the USA do not exist.
ever experiencing paternal imprisonment by age 14 years for US children by birth cohort
Sources: Western and Wildeman (2009);15 Wildeman (2009).16
The conditions of incarceration in the USA are also
extreme, a fact much less discussed in the literature. For
example, although precise estimates are not available for
Know imprisoned individual Imprisoned family member
50 the number of individuals in solitary confinement (a form
of imprisonment in which an inmate is isolated from any
40
human contact, often with the exception of guards and
Proportion (%)

30 other members of the prison staff), one study’s investigators

estimated that 100 000 prisoners are in solitary confinement
20
in the USA on any given day,17 a figure that suggests that
10 the USA has more prisoners in solitary confinement than
the UK has prisoners overall.
0
Because men who experience incarceration are
Imprisoned neighbour Trust imprisoned individual connected to families, their incarceration can have
50 implications for the health and wellbeing of women and
40 children as well. Furthermore, because of the vast racial
disparities in the risk of experiencing incarceration, the
Proportion (%)

30 spillover effects of incarceration for family members

20 could have implications not only among men but also
among whole communities, divided along racial and
10
ethnic lines. The proportion of black children who will
0 ever have a father imprisoned is high (figure 2). A black
White White Black Black White White Black Black child born in 1990 had a 25·1% chance of having their
women men women men women men women men
father sent to prison;16 for those whose fathers did not
Figure 3: Proportion of people in the USA who know individuals currently in state or federal prison, by race finish high school, the risk was roughly double that,
and gender at 50·5%. According to the Bureau of Justice Statistics,
Source: Lee and colleagues (2015).19 52% of state and 63% of federal inmates reported being
parents, to an estimated 1·7 million children (ie, 2·3% of
Although the causes of mass incarceration are American children).18
complex, social and criminal justice policies such as the The exposure of black families to incarceration cuts
so-called War on Drugs, the deinstitutionalisation of deeper still. Nearly half of black women have a family
people with mental illnesses, and punitive sentencing member or extended family member imprisoned
policies such as three-strike laws (mandating life (figure 3).19 For white women, the risk is only a quarter as
imprisonment for third offences of even relatively high, at 12%.19 Black people are also more likely than the
minor felonies) and mandatory minimum sentences overall population to know someone who is incarcerated,
(requiring judges to impose long sentences for specific have a neighbour incarcerated, or have a confidante
offences, even for some first-time offenders) incarcerated.19

1466 www.thelancet.com Vol 389 April 8, 2017


The pronounced disparities in exposure to incarceration
emphasise the salience of research into its health effects.
If incarceration substantially worsens the health of non-
incarcerated family members, mass incarceration could
be an important driver of broader health disparities
in the USA. Moreover, stark disparities in exposure
to incarceration probably extend to acquaintances,
neighbours, and confidantes, potentially amplifying the
contribution of incarceration to health inequities in
the USA.19
Effects on the health of prisoners
A growing number of studies have examined the effects
of incarceration on health.2–4 In this section, we review
these effects, which have also been reviewed elsewhere,2,3
including in a 2016 series in The Lancet that explored the
relationship between incarceration and communicable
diseases such as HIV, viral hepatitis, and tuberculosis.
The Series documented the burden of these
communicable diseases among prisoners,20 as well as
options for treatment21 and prevention22 in carceral
settings. Importantly—and by contrast with most
research in this area—the Series also considered the
implications of communicable diseases for the human
rights of prisoners23 and in regions where disease
transmission is an especially pressing problem (sub-
Saharan Africa,24 eastern Europe,25 and central Asia25).
We consider in more detail the family and community
consequences of mass incarceration, a topic that has
received little attention in the medical community.
Although we focus on adults, it is important to note that
incarcerated young people are at high risk for poor
physical and mental health.26,27
Research into the effects of current incarceration on
health is beset by several shortcomings beyond the
obstacles to causal inference mentioned in our
introduction. Scant research has examined objectively
measured health outcomes, and relatively few studies
have considered the mental health of current and former
inmates in the USA.28 Even fewer studies have explored
how different durations (eg, months or years) or types
(eg, prison or jail) of incarceration affect health. In a
similar vein, little research has considered how the
conditions of confinement (eg, solitary confinement) or
types of criminal justice policies (eg, three-strike laws)
affect health. Despite these caveats, most evidence
suggests that incarceration has strongly harmful effects
on the health of prisoners over their lifecourse.
Effects of current incarceration
Being incarcerated might, paradoxically, decrease mortality
and physical morbidity in the short term for some groups.
Black male prisoners, for instance, have far lower mortality
than similarly aged black men in the general population.29–32
Researchers speculate that the protective effects of current
imprisonment for this group might be driven by a
decreased risk of death by violence or accidents, reduced
www.thelancet.com Vol 389 April 8, 2017 1467
Series
access to illicit drugs and alcohol, and improved health-
care access, although the mechanisms are debated.29–32
However, the decreased mortality for black male prisoners
does not hold for other subpopulations of prisoners.29–32
Adjudication between these competing hypotheses is
beyond the scope of this Series paper, but we note that
prisons and jails are some of the only places in the USA
where health care is guaranteed by law (although the
often-dramatic variation in the quality of health care in
correctional facilities undermines the notion that this
mandate has been met). In 1976, the US Supreme Court
ruled in Estelle v Gamble that failure to provide basic
health care in correctional facilities violated the
constitutional prohibition against cruel and unusual
punishment. That ruling mandated that prisons and jails
provide acute care services, but, as the prison population For the Series on HIV and
has aged, prison health-care services have had to provide related infections in prisoners
see http://thelancet.com/series/
increased care for chronic diseases as well.4 aids-2016
For many Americans, correctional facilities provide
incarcerated adults with their first access to preventive
and chronic medical care.4 An estimated 40% of
individuals with chronic medical conditions are
diagnosed with a chronic condition while incarcerated,33
and 80% report seeing a medical provider while
incarcerated.34 Unfortunately, the quality of medical care
for chronic disorders in correctional settings is highly
variable,35 and overcrowding of correctional facilities
(especially prisons) has even reached the stage at which
judges have mandated the release of prisoners because
the level of overcrowding constitutes cruel and unusual
punishment.4
Compared with the non-incarcerated population,
incarcerated individuals have increased prevalence of
infectious disease (including sexually transmitted
diseases, HIV, and hepatitis C), chronic medical
conditions (eg, hypertension, diabetes, and asthma),
substance use disorders, and mental health disorders;34,36
Fazel and Baillargeon2 provide a more exhaustive list of
differences. While incarcerated, inmates also have a high
prevalence of vitamin D deficiency.37 However, findings
from a few studies have shown that incarceration can
improve the management of chronic conditions relative
to time spent outside of prison, especially in cases of
severe functional limitation38 and HIV.39 However, in the
time between release and re-incarceration, the probability
of viral suppression declines from roughly 50% to 30%.25
Unfortunately, because of data limitations, the effect of
incarceration on many of these disorders is unclear.
Overall, physical and psychological wellbeing worsens
for inmates, while mortality declines for black inmates.
Some study findings show worsening of depressive
symptoms40 and life satisfaction41 during incarceration.
Furthermore, inmates placed in solitary confinement
suffer greatly,41 and such confinement has serious short-
term and long-term repercussions.42,43 For instance,
inmates in solitary confinement in the New York City jail
system had 6·27 greater odds (95% CI 3·92–10·01) of
 Series
potentially fatal self-harm (including hanging and
ingesting poison) than those not placed in solitary
confinement.44 Nonetheless, most research into the
mental health of inmates, while acknowledging the high
prevalence of mental health problems in correctional
populations, has not tested whether mental health
changes as a result of incarceration.36
Of course, the total health effect of incarceration is a
product of time spent incarcerated and time spent free.
Individuals who experience incarceration spend, on
average, far more time out of prison than in it, with
much of that time happening after prison release since
most individuals experience their first incarceration by
their late 30s. For instance, black men who ever
experience prison incarceration spend 13·4% of their
working lives in prison.45 In other words, the average
prisoner spends roughly six times as long exposed to the
consequences of past incarceration as they do being
incarcerated. Hence, in considering the lifelong health
effects of incarceration, the period after release is of
crucial importance.
Effects of past incarceration
Although current incarceration has mixed effects on
prisoners’ health, past incarceration has a clearly
deleterious impact on health. Patients with chronic
conditions are often released without medications or a
follow-up appointment in the community.46 Even when
provided with a prescription at release, many do not
obtain them.47 Recently released inmates are less likely to
have a primary care physician, disproportionately use
emergency departments for health care, and have high
levels of preventable hospital admissions compared with
the general population.48 Because former inmates are
also at disproportionately high risk of mental health
problems that can interfere with their ability to follow
through with care for serious medical conditions,49 these
obstacles to receiving care are even more important.
Before the Affordable Care Act, four-fifths of former
inmates were uninsured at release; even among those
who are insured, many do not have the resources to pay
for their care.50 The Affordable Care Act might diminish
the health consequences of incarceration, because 10%
of the uninsured population has a recent history of
criminal justice involvement.51 Unfortunately, the refusal
on the part of several states to accept the Act’s expansion
of Medicaid coverage for the poor will probably attenuate
this benefit.
Upon release, former inmates often have no housing,
employment, and family support, and face discrimination
in finding jobs and housing.10,11 Individuals with health
issues are also confronted with the responsibility to
manage these problems, obtain health care, and keep up
with medications and appointments while also meeting
their basic needs. Individuals convicted of drug felonies
are also prohibited from accessing safety-net services
such as public housing and food subsidies.1 Given the
1468 www.thelancet.com Vol 389 April 8, 2017
many barriers that individuals face after incarceration, it
is unsurprising that they earn 30% less than similar
never-incarcerated individuals and that some of this
effect is driven by discrimination.10,11
Findings from studies of administrative data have
shown increased mortality among former inmates,
although the magnitude of this association varies.29,30,52
Investigators of one study53 that used a quasi-experimental
design to assess whether incarceration caused premature
mortality found an effect for women, but not for men,
after adjustment for confounders measured before
incarceration to ensure appropriate time-ordering of
confounders, explanatory variables, and dependent
variables (such as a history of illicit drug use, low
education, and pre-existing health problems). The
findings of this single study should be tested in further
research, especially because it is the sole study to suggest
that prison release might not increase mortality risk.
The evidence that a history of incarceration is associated
with increased morbidity is somewhat more consistent
than the data for mortality, although, again, it remains
unclear whether this relationship is indeed causal.
However, with the exception of the Coronary Artery Risk
Development in Young Adults (CARDIA) study54 and the
Veterans Aging Cohort study,55 few studies include both
incarceration measures and objective health data. In
CARDIA, the adjusted odds of left ventricular hypertrophy
(a common sequela of poorly controlled hypertension)
among the ever-incarcerated were 2·7 (95% CI 0·9–7·9)
compared with the never-incarcerated.54 In a matched
sample, a history of incarceration was associated with
1·8 times increased odds (95% CI 1·147–2·519) of having
hepatitis or tuberculosis.56 Studies including less precise
measures of health have also consistently linked previous
incarceration with poor health.3 Research has also shown
that the formerly incarcerated have very high prevalence
of psychiatric morbidity, with associations especially
pronounced for dysthymia and major depressive disorder,
and that incarceration is at least partly to blame for this
increase.40,49
The direct effects of incarceration on health
disparities
Although black populations have high levels of
incarceration, few studies have examined the direct
effects of incarceration on racial health disparities. The
scant research in this area supports two conclusions.
First, racial health disparities among prisoners are muted;
differences in mortality and morbidity between black and
white individuals are smaller in prison than in the
general population.2,38 Second, the post-release effects of
incarceration certainly contribute somewhat to racial
health disparities, although the magnitude of this effect is
unclear. In an analysis, investigators using data from the
National Longitudinal Survey of Youth56 concluded that
disparities in incarceration prevalence contributed greatly
to disparities between black and white men in midlife

self-reported health, as measured by the 12-Item Short
Form Health Survey; findings from another study38 that
used the same data and a measure of self-reported
functional limitation (defined as having had any health
problem that precluded working) showed that
incarceration explained only 6% of racial disparities in
this measure. Findings from a population-based study in
New York City57 suggested that disparities in incarceration
contributed substantially to disparities in asthma
prevalence.
Mass incarceration also creates methodological
problems in documentation of racial health inequities in
prospective longitudinal studies. Because black men
have very high levels of incarceration, they are more
likely than others to drop out of prospective longitudinal
surveys. As a result, research based on such surveys
could misestimate the magnitude of health disparities if
the health status of black men who experience
incarceration is worse than those who do not, as most
research suggests is indeed the case.58
The indirect effects of incarceration on health
Overview
Until the past 10 years, most research into the health
consequences of incarceration had focused exclusively
on how incarceration affects those who experience it.
However, as incarceration has become increasingly
common, researchers have become aware of the broader
health effects of mass incarceration on families,
communities, and even nations. Because little research
has examined the spillover effects of mass incarceration
on direct measures of health, our Series paper also
encompasses broader studies of wellbeing. In this area,
we are unable to make distinctions between the effects of
current and past incarceration.
Effects of family member incarceration on health
Research into the broader family consequences of
incarceration suggests myriad channels through which
incarceration might matter. For example, incarceration
decreases the financial contributions individuals can
make after release;59 while incarcerated, their financial
contributions are virtually nil.60 Because keeping in touch
with a prisoner is costly,52 incarceration exacerbates
financial hardships beyond what would be expected due
just to decreased earnings. Incarceration also disrupts
romantic unions.61 The resulting decrease in adults’ time
available for household duties might reduce the time
spent on health-related activities. Having an incarcerated
family member—and re-incorporating a former
inmate—is also stressful. Moreover, if the stigma
attached to incarceration pervades families, as research
suggests,62,63 having a family member incarcerated could
reduce the social support available to families.64
Although incarceration can also affect prisoners’
siblings, husbands, boyfriends, and parents, most
research has focused on the heterosexual partnerships
www.thelancet.com Vol 389 April 8, 2017 1469
Series
and children of male prisoners. Findings from two
studies have suggested a link between parental
incarceration and child mortality: investigators of a
US study65 found elevated infant mortality, whereas
findings from a Danish study66 of mortality up to age
18 years showed increased mortality among sons but not
daughters of incarcerated men. A few other studies have
also shown evidence of gender-specific effects; parental
incarceration was associated with significantly more
weight gain67 and higher levels of inflammatory markers
(eg, C-reactive protein) among adolescent girls than
among boys.68 Yet, given the dearth of research in this
area, these findings about gender differences should be
interpreted with some caution.
Although very few studies have used physiological
measures to assess the health of children of incarcerated
parents, the literature assessing self-reported, caretaker-
reported, and teacher-reported outcomes for children is
vast. These study findings tell a consistent story: paternal
incarceration is associated with behavioural and mental
health problems throughout childhood,69 and a host of
poor outcomes (including increased prevalence of
substance misuse70) in adolescence and adulthood.71–73
The most wide-ranging assessment of the effect of
parental—mostly paternal—incarceration used data
from the National Survey of Children’s Health,74 showing
links to a host of negative health outcomes among
children, including self-rated health, depression, anxiety,
asthma, and obesity. Findings from a study75 that used
data from the National Longitudinal Study of Adolescent
Health (Add Health) underscored that many of the
negative consequences of paternal incarceration continue
throughout adolescence and early adulthood.75
For maternal incarceration, the story is more
complicated. A handful of studies have linked maternal
incarceration with worse self-reported health,75
educational,76 and criminal justice outcomes77 for
children. However, other study findings78,79 have shown
no effects on children after adjustment for factors that
are associated with the risk of incarceration and poor
child health, such as low parental education, financial
instability, and criminal activity. Given the paucity of
studies on this topic, and evidence that maternal
incarceration helps some children and harms others,80
the net effect of maternal incarceration on children
remains an open question.
Fewer quantitative studies (but many qualitative
ones60,62,63) have assessed how incarceration affects other
adult family members. Women whose partners are
incarcerated experience substantial mental health
deterioration,81 as well as a host of elevated risk factors
for cardiovascular disease.82 However, this effect on
cardiovascular risk factors was not observed among men
in the household.82 We must note that the effect of
incarceration on family violence is unclear. There is little
doubt that incarcerated individuals83 and their families65,84
experience great exposure to violence throughout their
 Series
lives. The incarceration of a family member might
increase family violence by destabilising already-
disadvantaged homes. Alternatively, the removal of
violent family members from the household might
decrease exposure to violence for the remaining
household members. Existing research provides little
guidance regarding either possibility.
Effects of incarceration on communities
Neighbourhoods with high levels of incarceration are
associated with poor population health, including high
prevalence of asthma, sexually transmitted infections, and
psychiatric morbidity;85–90 the challenge is to decipher
whether imprisonment, rather than the factors that lead to
imprisonment, is the driver. All studies done so far85–90
have tested a linear effect of imprisonment, yet a non-
linear relationship between neighbourhood-level
prevalence of incarceration and community health is also
possible. Clear85 proposed a hypothesis of coercive
mobility, suggesting that the crime-fighting benefits of
imprisonment at low levels are substantial, but that these
benefits fall as imprisonment increases, and that further
increases in imprisonment raise—rather than reduce—
crime. Testing of this hypothesis is difficult. If true, it has
profound implications for understanding the effect of
incarceration on community health, not only because
high levels of violent crime remain one of the most serious
threats to public health in these communities but also
because it suggests that the public health consequences of
incarceration in these communities could be far larger
than an additive model would imply.
Indirect effects of incarceration on states, nations, and
health disparities
The indirect effects of incarceration on states and
nations, and health disparities more broadly, are most
readily measured at the population level. Hence, we
discuss all three in the same section.
Variation at the state level has rarely been used to
analyse the health effects of differences in incarceration
prevalence, despite the availability of state-level data about
key health outcomes and incarceration. Findings from a
few studies have suggested that states with large numbers
of former inmates have poorer-quality health-care
systems,91 lower life expectancy,92 and higher incidence of
HIV infection93 and infant mortality65 than do states with
few former inmates. These state-level studies have also
shown a link between incarceration prevalence and health
disparities. Findings from one study,93 for instance,
showed that mass incarceration explained most of the
racial disparities in the incidence of HIV infection.
There is less country-level than state-level research into
the relationship between incarceration and health. Of
these studies, two stand out. Stuckler and colleagues6
showed that increased incarceration was linked with
increased tuberculosis incidence (a 1% increase in
incarceration was associated with a 0·3% increase in
1470 www.thelancet.com Vol 389 April 8, 2017
tuberculosis incidence) and increased multidrug-resistant
tuberculosis. Findings from another cross-national study5
showed that increases in incarceration were associated
with substantial worsening of life expectancy and infant
mortality, although the population-level consequences of
incarceration for health were significantly worse in the
USA than in other developed democracies. This analysis
suggested that US life expectancy would have increased
51·1% more and infant mortality would have fallen
39·6% more from 1983 to 2005 if incarceration had
remained at the mid-1980s level. Taken together, these
findings suggest that mass incarceration could contribute
to both within-country and between-country inequalities
in health.
Finally, as for longitudinal studies, the US point-in-
time surveys underlying much of the epidemiological
and health services research (eg, the National Health
Interview Survey) exclude inmates,94 resulting in
substantial misestimates of disease prevalence and,
particularly, racial disparities. With so many minority
men behind bars, their exclusion from almost all
research provides a fanciful picture of progress in
the USA, especially for health inequities between black
and white populations.
Conclusions and next steps
Soaring incarceration since the mid-1970s has
profoundly affected health in the USA, especially in poor
and minority communities. Incarceration might
temporarily improve some physical health outcomes
during imprisonment. However, after release and over
the lifecourse more broadly, imprisonment seems to
worsen both physical and mental health, although we
make this statement with some hesitation because few
(if any) strong causal tests are available and the health
conditions considered so far have been limited. Although
data are sparse, mass incarceration also probably
worsens the health of the female partners and children
of inmates.
Because of the uneven distribution of incarceration,
these ill effects could be a significant contributor to racial
health disparities. The criminal justice system has
become an institution—like the education system—that
both reflects systematic and institutionalised racism and
exacerbates existing inequities.3,11,71 Moreover, as some
recent research into the relationship between
incarceration and population health indicates,5 the
uniquely high incarceration prevalence in the USA might
partly underlie the country’s poor showing relative to
other developed democracies on population health
measures over the past 40 years.
On a more hopeful note, soaring costs, overcrowding
of prisons and jails, and a spotlight on overly aggressive
policing in minority communities have engendered
agreement that mass incarceration has failed and should
be reversed. There is also increasing recognition,
although not consensus, that policing should be altered
 Series

Total Arkansas Florida Kentucky

1000

800
Mortality per 100 000

600

400

200

Louisiana Maryland Montana New York

1000

800
Mortality per 100 000

600

400

200

North Carolina Ohio Oregon South Carolina

1000

800
Mortality per 100 000

600

400

200

Tennessee Texas Utah Wisconsin

1000

800
Mortality per 100 000

600

400

200

0
Probation Local jail State Parole Probation Local jail State Parole Probation Local jail State Parole Probation Local jail State Parole
prison prison prison prison

Figure 4: Mortality of individuals on probation, incarcerated in local jails, incarcerated in state prisons, and on parole in 15 US states, 2000–12
Calculations based on data from the Annual Parole Survey and Annual Probation Survey;96 and from Noonan and Ginder (2014).97

in key ways (eg, to limit stops to those absolutely
necessary and to promote less adversarial contact
between the police and the community than frequently
occurs at present). The shift in the nation’s approach to
criminal justice and drug sentencing has led to a small
decrease in the prison population, a fall of 2·9% since its
peak in 2009.95 The pace of downsizing could be
quickened with more sweeping reforms in drug
sentencing, reduced admissions of technical parole
violators, expanded community corrections for those
convicted of low-level property and drug crimes, and
medical paroles for sick and elderly inmates. Those
concerned about mass incarceration—and health
disparities—should advocate for such reforms, in

www.thelancet.com Vol 389 April 8, 2017 1471

 Series
conjunction with improved access to health care and
social services for individuals who have been affected by
the criminal justice system. However, even these changes
would cut the penal population by just 30%, because
much of the increase in incarceration is due to the
adoption of long sentences for violent offenders.
Moreover, shrinking the imprisoned population size
while expanding the population under social control in
the community will probably not ameliorate health
inequity unless the roots of mass incarceration
are addressed through broader efforts to provide
opportunities and conditions for people in marginalised
communities to improve their lives. Our analyses of data
from the Bureau of Justice Statistics highlight this point.
As shown in figure 4, the crude mortality of probationers
and parolees exceeds that of state prisoners and jail
inmates in nearly every state.96,97 These data are
unadjusted by age, race, and other traits that might
account for these differences. However, until US data
collection systems are redesigned, we will not know the
health risks for the roughly 6 million Americans on
probation.
Were the USA to return to the levels of incarceration of
the 1970s, at least a half a million people employed by the
criminal justice system could lose their jobs, and
63 million individuals would still have criminal records.
The criminal justice system is so deeply rooted in
America’s political system and socioeconomic structures
that the damage to the health of our communities cannot
be mitigated without addressing the root causes of mass
incarceration and the forces that inevitably seek to
maintain it.
True understanding of the health consequences of
mass incarceration and necessary changes in criminal
justice policy requires investment in improved data, the
inclusion of several questions about criminal justice
exposure in national health surveys, and the linkage of
administrative data about incarceration with data for
income, employment, housing, educational outcomes,
and health services. We should also invest in a host of
experiments that test interventions to mitigate the
negative direct and indirect health effects of incarceration
and community corrections, and seek perspectives
that facilitate engagement between physicians,
epidemiologists, and criminologists.98 There is a special
urgency to develop effective interventions that take into
account the experiences of women and juvenile
offenders. There is also a pressing need to consider
whether differential processing within the criminal
justice system of individuals with mental health
conditions—wherein individuals with more resources
are able to gain access to treatment (and avoid jail or
prison stay) and those with fewer resources are not—
could contribute to growing racial, ethnic, and class
disparities in physical and mental health.
Improved data would help us to understand how mass
incarceration has contributed to—and will continue to
1472 www.thelancet.com Vol 389 April 8, 2017
contribute to—health inequity, and facilitate undoing the
damage it has caused. But research is not enough to stem
the health effects of mass incarceration on individuals,
families, and communities, or to mitigate existing health
inequities. As physicians and researchers, we should
engage in conversations about the interplay between
racism, social control, and health. Such discussions must
also address the health consequences of living in a
community subject to overly aggressive policing, and
engage communities of colour to build trust, develop
solutions, and ultimately improve health outcomes.
Contributors
CW and EAW contributed equally to all components of this Series paper.
Declaration of interests
We declare no competing interests.
Acknowledgments
CW is supported by the Rockwool Foundation and by a visiting fellowship
from the Bureau of Justice Statistics. EAW is supported by a visiting
fellowship from the Bureau of Justice Assistance. The views expressed in
this Series paper should not be considered those of the Bureau of Justice
Statistics, the Bureau of Justice Assistance, the Office of Justice Programs,
or the National Institute of Justice.
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67 Roettger ME, Boardman JD. Parental incarceration and
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68 Boch SJ, Ford JL. C-reactive protein levels among U.S. adults
exposed to parental incarceration. Biol Res Nurs 2015; 17: 574–84.
69 Wakefield S, Wildeman C. Children of the prison boom: mass
incarceration and the future of American inequality.
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70 Roettger ME, Swisher RR, Kuhl DC, Chavez J.
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71 Wildeman C, Muller C. Mass imprisonment and inequality in
health and family life. Annu Rev Law Soc Sci 2012; 8: 11–30.
72 Foster H, Hagan J. Punishment regimes and the multilevel effects
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73 Porter LC, King RD. Absent fathers or absent variables? A new look
at paternal incarceration and delinquency. J Res Crime Delinquency
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74 Turney K. Stress proliferation across generations? Examining the
relationship between parental incarceration and childhood health.
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75 Lee RD, Fang X, Luo F. The impact of parental incarceration on the
physical and mental health of young adults. Pediatrics 2013;
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76 Hagan J, Foster H. Children of the American prison generation:
student and school spillover effects of incarcerating mothers.
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77 Huebner BM, Gustafson R. The effect of maternal incarceration on
adult offspring involvement in the criminal justice system.
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78 Cho RM. Impact of maternal imprisonment on children’s
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79 Wildeman C, Turney K. Positive, negative, nor null? The effects of
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80 Turney K, Wildeman C. Detrimental for some? Heterogeneous
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88 Khan MR, Doherty IA, Schoenbach VJ, Taylor EM, Epperson MW,
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 Series

America: Equity and Equality in Health 5

Population health in an era of rising income inequality:
USA, 1980–2015
Jacob Bor, Gregory H Cohen, Sandro Galea

Income inequality in the USA has increased over the past four decades. Socioeconomic gaps in survival have also Lancet 2017; 389: 1475–90
increased. Life expectancy has risen among middle-income and high-income Americans whereas it has stagnated See Editorial page 1369
among poor Americans and even declined in some demographic groups. Although the increase in income See Comment pages 1376
inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has and 1378
occurred lower in the distribution—ie, between the poor and upper-middle class. Growing survival gaps across This is the fifth in a Series of
income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong five papers about equity and
equality in health in the USA
association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and
Department of Global Health
substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising
(J Bor ScD) and Department of
inequality including unequal access to technological innovations, increased geographical segregation by income, Epidemiology (J Bor,
reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have G H Cohen MPhil,
reduced access to salutary determinants of health among low-income Americans. Having missed out on decades Prof S Galea MD), Boston
University School of Public
of income growth and longevity gains, low-income Americans are increasingly left behind. Without interventions Health, Boston, MA, USA
to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century
Correspondence to:
health-poverty trap and the further widening and hardening of socioeconomic inequalities in health. Prof Jacob Bor, Department of
Global Health, Boston University
Introduction to the extent that socioeconomic inequalities in health are School of Public Health, Boston,
MA 02118, USA
Income inequality in the USA has increased dramatically avoidable, measurement of health gaps helps to identify
jbor@bu.edu
over the past four decades. The share of incomes going to opportunities to target future interventions.
See Online for infographic
the wealthiest 10% increased from 33% of total earnings www.thelancet.com/
in 1978 to 50% in 2014—a level of inequality not seen Search strategy and selection criteria infographics/us-health
since before the Great Depression.1 Incomes for poor and
middle-income Americans have barely changed since the We reviewed studies reporting trends in survival inequalities in the
1970s and, adjusted for inflation, have actually declined USA for the period 1980–2015. We searched PubMed and Google
since 2000 (figure 1). Given the strong and nearly Scholar for English-language articles published between Jan 1,
universal association between socioeconomic status and 1990, and Oct 30, 2016, using the following terms: “((income) or
health,2–6 it is natural to ask whether rising gaps in (education)) and ((mortality) or (life expectancy)) and (united
income might be associated with widening gaps in health states) and ((longitudinal) or (changes) or (trends) or (over time)).”
and longevity between rich and poor Americans. We then added the terms “((inequality) or (disparity))” to the first
Our review focuses on income-related and education- search. We manually searched the bibliographies of relevant articles
related inequalities in health. Other papers in the Series and used Google Scholar to identify articles citing the relevant
address racial inequalities in health—particularly the article. We included articles if they compared survival in a
strikingly worse health outcomes of African-Americans— high-socioeconomic status group versus a low-socioeconomic
and review the implications of economic inequality for status group, stratified by income or education, at least a decade
the US medical care system. apart during the period 1980–2015. Articles were critically
appraised to assess socioeconomic strata compared, survival
Why socioeconomic inequalities in health matter outcomes measured, whether a period versus cohort
Measurement of socioeconomic inequalities in health— perspective was used, whether adjustments were made for
also known as health inequalities—is important for several changing composition across strata, and whether the data
reasons. Health is a key aspect of wellbeing and health presented reflect measured outcomes or projections.
inequalities can compound (or mitigate) existing differ­ A listing of all studies identified in our review and key results
ences in wellbeing according to income. Knowledge of the can be found in the appendix. Our review highlights studies
distribution of health across income groups offers a more that presented raw survival measures by socioeconomic
complete picture of how wellbeing is distributed across group in an early year and a late year (or gaps in an early and
society and the effects of policy options. For example, late year), such that changes in survival gaps could be
because the poor die younger, they are short-changed by calculated. Findings of studies reporting only relative
age-targeted entitlement programmes such as Medicare measures were also generally consistent, and are presented
(the public health insurance programme for elderly people) in the appendix and discussed in the text.
and the Social Security retirement system.7 Additionally,

www.thelancet.com Vol 389 April 8, 2017 1475

 Series
Key messages
• Gaps in mortality and life expectancy according to income and education have widened
during the period 1980–2014.
• Life expectancy has stagnated and even declined in some groups—eg, white women
without a high school diploma.
• Growth in health inequalities has been most pronounced in the bottom half of the
income distribution. Since 2001, the poorest 5% of Americans experienced close to
zero gains in survival. At the same time, middle-income and high-income Americans
have gained over 2 years in additional life expectancy.
• Widening gaps in survival across income percentiles since 2001 are only partially
explained by falling incomes among the poor. The relationship between income and
survival has also grown stronger, with poverty becoming an increasingly important
risk factor for mortality in the early 21st century.
• The income–survival gradient has become steeper, in part, because of several
proximate factors: a shift in the burden of smoking and (to a lesser extent) obesity,
underuse of essential medical care, and increased substance abuse and self-harm in
lower-socioeconomic status groups.
• Distal explanations for the rising gradient are harder to evaluate, but might include
differential changes in access to and uptake of determinants of health, ranging from
fresh fruit and vegetables to information on new risk factors to new medical
procedures; increasing geographical segregation that exacerbates inequalities in
access to salutary health amenities; reduced economic mobility leading to greater
persistence of poverty; mass incarceration; and, possibly, the erosion of public
subsidies that previously shielded the poor from exposure to the market-determined
prices of health insurance and other health inputs. These factors might have reduced
access to key salutary determinants of health among low-income Americans,
exacerbating income losses that have occurred since 2001.
• Changes in survival gaps over time might substantially underestimate the growth in
health inequalities across birth cohorts. The gap in cohort life expectancy between the
top and bottom income quintiles is projected to increase by nearly a decade within a
single generation—from the 1930–60 birth cohort.
• Rising health inequalities should be addressed to avoid the emergence of a
21st-century health-poverty trap.
See Online for appendix Health inequalities are particularly pernicious because
they can reproduce and reinforce gaps in income and
wealth, with negative feedback loops creating a health-
poverty trap. Poor health can limit economic productivity,8
bankrupt households,9 and impoverish families.10 Poor
health in childhood can also have long-term con­sequences
for physical and cognitive development,11,12 educational
attainment,13,14 and future earnings.14,15 Health deficits
might even have intergenerational consequences,16
reproducing inequalities in income, wealth, and human
capital (ie, the education, training, and health that facilitate
occupational success) in future generations.12
Health inequalities should be understood and addressed
regardless of whether they are causally linked to income
inequality. However, if the relationship were causal then
widening health gaps would be a troubling social cost of
rising income inequality, and income redistribution could
be an important policy lever to improve population health.
Rising income inequality could cause increasing
health inequalities through two separate channels. First,
divergence in incomes might lead mechanically to
1476 www.thelancet.com Vol 389 April 8, 2017
divergence in health (by income) due to a direct causal
relationship between individual-level income and
health.17–19 Second, income inequality might also have an
indirect effect on health—eg, by strengthening the
political power of the wealthy with a resulting shift in
policy priorities20,21 or via changes in social capital22 (the
shared connections and values between people that
encourage advantageous cooperation) or social
cohesion.23 Studies of inequality and health have not
found a consistent indirect effect of inequality on
aggregate health outcomes; however, this literature is
contested.24,25 Still, the largest rise in income inequality
since the Great Depression offers a case study to
investigate how, if at all, changes in income distribution
might be linked to inequalities in health.
In this review, we synthesise evidence on trends in
income-related and education-related survival inequalities,
and discuss proximate and distal mechanisms that might
explain these trends.
Growing gaps in survival by income: a review
Absolute gaps in survival between rich and poor have
grown over the past 40 years (table, figure 2; see appendix
for a complete list of studies reviewed), with nearly all
studies reviewed reporting increases in health inequalities
regardless of choice of socioeconomic status measure
(income vs education), choice of outcome (mortality rates
vs life expectancy), and time period covered. Increases in
survival inequalities were qualitatively large, with life
expectancy gaps between high and low socioeconomic
status groups growing by 1–2 years and even more in
some demographic groups. With a few exceptions, the
smallest absolute increases in survival gaps were observed
in non-elderly populations with lower baseline mortality
and in fact represented large relative increases in health
inequalities (table).26,33,35
In addition to general agreement across studies that
health inequalities have widened, three noteworthy
patterns emerged. First, we noted consistent differences
by gender. Baseline survival gaps were generally larger
among men than among women; yet the growth in
survival gaps among women was equal to—or exceeded—
the growth in survival gaps among men, with the result
that health inequalities increased much faster for women
than for men in relative terms. Second, life expectancy
actually fell in some categories, particularly in white
women with low income or educational attainment.29,31,32
Evidence on survival trends in black women with low
socioeconomic status was mixed and more limited.29,31
Survival gaps did not increase among Hispanic
Americans.31 Third, studies that assessed mortality
experiences across birth cohorts, rather than differences
across periods, reported much larger increases in survival
disparities.7,27 This finding is to be expected: if cohort
life expectancy is increasing over time, then period life
expectancy, which averages across cohorts, will under­
estimate those increases. Cohort measures involve

projections of survival patterns at older ages and thus
contain substantial uncertainty. At the same time, the
period measures reported in most studies might
substantially underestimate the actual growth in
socioeconomic status-related health inequalities from
one generation to the next.
Several studies documented widening survival gaps by
income levels. Cristia26 linked data from the Survey of
Income and Program Participation to tax and Social
Security records and assessed trends in survival across
quintiles of long-run earnings, comparing an early period
centred at 1990 and a later period centred at 2000. Life
expectancy between 35 and 75 years of age increased for
wealthy men and women, but did not change for poor men
and actually declined for poor women (table). The top-to-
bottom life expectancy differential across income quintiles
increased from 2·7 to 3·6 years for men and 0·7 to 1·5 years
for women. Cristia further reports that the ratio of mortality
in poor versus rich Americans approximately doubled for
35–64 year olds, with smaller increases among 65–75 year
olds.26 Cristia’s findings are consistent with those of
Krieger and colleagues35 and Singh and Siahpush,36 who
found widening survival gaps during the 1980s and 1990s
by county-level income and deprivation measures.
Income-based survival gaps continued to widen in the
2000s. Chetty and colleagues6 linked income tax records to
survival information collected by the Social Security system.
Between 2001 and 2014, the life expectancy gradient across
income quantiles became noticably steeper (table). Men
and women in the poorest 5% of households experienced
close to zero net increase in life expectancy during this
period, whereas women in the top half of the income
distribution—and men in the top quarter of the
distribution—gained more than 2·5 years of life expectancy
(figure 3).6 The sharpest divergence in longevity occurred
between poor and upper-middle-income Americans. We
found no change in the survival gap between upper-middle-
income and high-income Americans.
We note that although health inequalities widened
specifically among lower-income and middle-income
Americans during the period 2001–14, a very strong
gradient remained between income percentile and health
throughout the income distribution, with no evidence of
a threshold effect; the differences in life expectancy
between the wealthiest 1% and poorest 1% were
14·6 years for men and 10·1 years for women. The
importance of income across the full distribution echoes
findings from other individual-level studies, most
famously the Whitehall study3 of British civil servants.
A strength of Chetty and colleagues’ and Cristia’s
approach is that they adjust for changing composition by
assessing survival trends within income quantiles, rather
than levels. This technique reduces the potential for
selection bias that emerges when the proportion of the
population in different socioeconomic status categories
shifts over time. At the same time, health trends by
income quantile might reflect both changes in income
www.thelancet.com Vol 389 April 8, 2017 1477
Series
Top 1%
90th percentile
80th percentile
Annual household income, excluding top 1% ($1000s)
200 1000
60th percentile
Annual household income, top 1% ($1000s)
40th percentile
20th percentile
10th percentile
800
150
100 600
50 400
0 200
1970 1980 1990 2000 2010
Year
Figure 1: Inflation-adjusted annual household income at selected percentiles, 1967–2014
All series show percentiles of the distribution except for top 1%, which shows the mean of the top 1%. All income
series except for the top 1% are plotted against the left vertical axis, displaying incomes from $0 to $200 000.
The top 1% is plotted against the right vertical axis, displaying incomes from $200 000 to $1 000 000. Data are
from the US Census Bureau Current Population Survey, 1968–2015 Annual Social and Economic Supplements and
World Wealth and Income Database. Income is expressed in 2014 US$.
for a given quantile as well as changes in the relationship For results of the US Census
between income and health (panel 1). Bureau Current Population
Survey see http://www.census.
A natural question is whether the expansion of health gov/programs-surveys/cps.html
inequalities across income quantiles is simply a
For more on the World Wealth
mechanical result of rising income inequality. If the and Income Database see
relationship between income and survival were held http://wid.world
constant, increased dispersion in the earnings
distribution would be expected to lead to growing gaps in
survival as the average incomes of the top and bottom
quantiles diverge. The alternative (and perhaps
complementary) hypothesis is that health inequalities
across income quantiles might have widened because the
relationship between actual income levels and health (ie,
the slope of the gradient) has changed over time.
To shed light on the contribution of distribution
changes versus slope changes, we decomposed the
quantile-based results from Chetty and colleagues6 using
their supplementary data (figure 4). We found that both For more on the data compiled
of these explanations have played a part in widening by Chetty and colleagues see
https://healthinequality.org
health inequalities. Since 2001, annual inflation-adjusted
household earnings have fallen for Americans in the
bottom two thirds of the income distribution (figure 4),
with the largest relative losses experienced in the lower
part of the income distribution. From 2001 to 2014,
earnings fell by 17% for men and women in households
at the 25th income percentile. Americans at the top of the
distribution experienced much smaller (or non-existent)
relative losses. The decline in incomes among lower-
earners and moderate-earners is a new trend since 2000,
reversing—and erasing—previous earnings gains during
the 1990s (figure 1).
Falling incomes among poor Americans were one
explanation for the divergence of life expectancy across
 Series

Age Socioeconomic Early Late Adjusts for Measure of survival Change in Change in Survival gap, Survival gap, Absolute change
(years) groups compared year year changes in (units) survival, survival, early year late year in survival gap
composition low SES high SES (percent change)
Income
Cristia (2009)26
Men 35–75 1st vs 5th quintile 1983 2003 Yes Period life expectancy 0·0 0·9 2·7 3·6 0·9 (33%)
(years)
Women 35–75 1st vs 5th quintile 1983 2003 Yes Period life expectancy –0·4 0·4 0·7 1·5 0·8 (114%)
(years)
Chetty et al (2016)6
Men ≥40 1st vs 4th quartile 2001 2014 Yes Period life expectancy 1·0 2·6 8·4 10·0 1·6 (19%)
(years)
Women ≥40 1st vs 4th quartile 2001 2014 Yes Period life expectancy 1·3 3·0 4·5 6·2 1·7 (38%)
(years)
Men ≥40 1st vs 20th ventile 2001 2014 Yes Period life expectancy 0·3 2·3 11·5 13·5 2·0 (17%)
(years)
Women ≥40 1st vs 20th ventile 2001 2014 Yes Period life expectancy 0·0 2·9 6·3 9·1 2·9 (44%)
(years)
Waldron (2007)27
Men ≥65 Top vs bottom half 1912 1941 Yes Cohort life expectancy 1·3 6·0 0·7 5·4 4·7 (671%)
cohort cohort (years)
NAS (2015)7
Men ≥50 1st vs 5th quintile 1930 1960 Yes Cohort life expectancy –0·5 7·1 5·1 12·7 7·6 (149%)
cohort cohort (years)
Women ≥50 1st vs 5th quintile 1930 1960 Yes Cohort life expectancy –4·0 5·7 3·9 13·6 9·7 (249%)
cohort cohort (years)
Education*
Ho and Fenelon (2015)28
White men ≥50 <High school vs 1980 2006 No Period life expectancy 4·3 5·4 4·3 5·4 1·1 (26%)
university (years)
White ≥50 <High school vs 1980 2006 No Period life expectancy 2·4 4·5 2·5 4·6 2·1 (84%)
women university (years)
Meara et al (2008)29
All ≥25 <High school vs 1990 2000 Yes Period life expectancy 0·0 1·6 5·4 7·0 1·6 (30%)
university (years)
White men ≥25 <High school vs 1990 2000 Yes Period life expectancy 0·2 1·8 6·2 7·8 1·6 (26%)
university (years)
Black men ≥25 <High school vs 1990 2000 Yes Period life expectancy 2·0 3·3 7·1 8·4 1·3 (18%)
university (years)
White ≥25 <High school vs 1990 2000 Yes Period life expectancy –0·9 1·0 3·5 5·4 1·9 (54%)
women university (years)
Black ≥25 <High school vs 1990 2000 Yes Period life expectancy –0·2 1·6 3·6 5·4 1·8 (50%)
women university (years)
Hendi (2015)30
White men 25–85 <High school vs 1991 2005 Yes Period life expectancy 1·6 1·8 6·7 6·8 0·1 (1%)
university (years)
White 25–85 <High school vs 1991 2005 Yes Period life expectancy –0·7 1·5 3·8 6·0 2·2 (58%)
women university (years)
Olshansky et al (2012)31
All men ≥25 <High school vs 1990 2008 No Period life expectancy ·· ·· 13·4 14·2 0·8 (6%)
university (years)
White men ≥25 <High school vs 1990 2008 No Period life expectancy –3·4 4·6 5·1 13·2 8·1 (159%)
university (years)
Black men ≥25 <High school vs 1990 2008 No Period life expectancy 3·2 4·6 6·3 10·1 3·8 (60%)
university (years)
Hispanic ≥25 <High school vs 1990 2008 No Period life expectancy 6·4 6·4 5·5 5·5 0 (0%)
men university (years)
(Table continues on next page)

1478 www.thelancet.com Vol 389 April 8, 2017

 Series

Age Socioeconomic Early Late Adjusts for Measure of survival Change in Change in Survival gap, Survival gap, Absolute change
(years) groups compared year year changes in (units) survival, survival, early year late year in survival gap
composition low SES high SES (percent change)
(Continued from previous page)
All women ≥25 <High school vs 1990 2008 No Period life expectancy ·· ·· 7·7 10·3 2·6 (34%)
university (years)
White ≥25 <High school vs 1990 2008 No Period life expectancy –5·3 3·3 1·9 10·5 8·6 (453%)
women university (years)
Black ≥25 <High school vs 1990 2008 No Period life expectancy 0·1 4·9 2·0 6·6 4·6 (230%)
women university (years)
Hispanic ≥25 <High school vs 1990 2008 No Period life expectancy 3·2 2·6 3·6 3·0 –0·6 (–17%)
women university (years)
Montez and Berkman (2014)32
Men 45–84 <High school vs 1986 2006 No All-cause mortality (deaths –3·30 –2·50 32·30 31·50 –0·80 (–2%)
university per 1000 person-years)
Women 45–84 <High school vs 1986 2006 No All-cause mortality (deaths 4·90 –0·70 16·90 22·50 0·60 (33%)
university per 1000 person-years)
Ma et al (2012)33
Men 25–64 <High school vs 1993 2007 No All-cause mortality (deaths –0·38 –0·96 4·16 4·73 0·57 (14%)
university per 1000 person-years)
Women 25–64 <High school vs 1993 2007 No All-cause mortality (deaths 0·39 –0·52 1·65 2·56 0·91 (55%)
university per 1000 person-years)
Case and Deaton (2015)34
Women 45–54 <High school vs 1999 2013 No All-cause mortality (deaths 1·34 –0·57 ·· ·· 1·91 (··)
university per 1000 person-years)
County socioeconomic conditions
Krieger et al (2008)35
All <65 1st vs 5th quintile, 1980 2000 No All-cause mortality (deaths –0·67 –0·87 0·85 1·05 0·20 (24%)
county income per 1000 person-years)
White <65 1st vs 5th quintile, 1980 2000 No All-cause mortality (deaths –0·53 –0·84 0·56 0·87 0·31 (55%)
county income per 1000 person-years)
Non-white <65 1st vs 5th quintile, 1980 2000 No All-cause mortality (deaths –1·47 –1·42 1·82 1·77 –0·05 (–3%)
county income per 1000 person-years)
Singh and Siahpush (2006)36
All ≥0 1st vs 10th decile, 1980 2000 No Period life expectancy 1·7 3·4 2·8 4·5 1·7 (61%)
county deprivation (years)
Men ≥0 1st vs 10th decile, 1980 2000 No Period life expectancy 2·8 4·4 3·8 5·4 1·6 (42%)
county deprivation (years)
Women ≥0 1st vs 10th decile, 1980 2000 No Period life expectancy 0·5 2·5 1·3 3·3 2·0 (154%)
county deprivation (years)

Results of all studies identified that assessed time trends in absolute survival gaps by income and education. Studies that adjusted for changes in composition accounted in some way for changing population
shares across SES categories. We report absolute changes in survival over time in high-SES and low-SES groups, to highlight differences in the evolution of mortality patterns within groups. We report survival
gaps37 between high-SES and low-SES groups in the early period and the late period (early year and late year are the first and last years respectively of the early and late periods compared) to capture how health
inequalities have changed. We present the absolute change in survival gaps, a difference-in-differences type measure, to establish whether health inequalities are growing. Widening survival gaps are reflected as
positive changes, and are presented in the units of the outcome (years for life expectancy; deaths per 1000 person-years for mortality rates). The percent change in survival gaps enables comparison across
different outcomes; however, important differences across the studies in measures and methods used make direct comparisons difficult. SES=socioeconomic status. NAS=National Academies of Sciences,
Engineering, and Medicine. *University education refers to undergraduate studies.

Table: Changes in survival gaps by income, education, and county socioeconomic conditions, 1980–2014

income quantiles since 2001 (figure 3); but they were not
the only—and indeed not the primary—explanation.
When the income–health gradient was held constant at its
2001 slope, changes in income distribution explained only
about one third of the increase in the top versus bottom
quartile life expectancy gap in men and about one sixth of
the increase in women. More importantly, the income–
survival gradient changed as well, becoming substantially
stronger over time (figure 4). In 2001, female life
expectancy was on average 1·7 years higher for every log-
point of income; by 2014, the gradient had increased to
2·4 years per log-point. (Incomes increase by a factor of
2·7 for every log-point—eg, from US$22 000 to $60 000 to
$163 000.) In men, the gradient increased from 3·2 years
per log-point in 2001 to 3·7 years per log-point in 2014.
The gradient for women is clearly steeper in the later
period (figure 4). In men, the change in slope—although
similar in absolute magnitude—is more difficult to see
because the baseline gradient was steeper and non-linear
(figure 4).

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700
600
500
Change in survival gap (%)
400
300
200
100
0
–100
Income Education County
socioeconomic
conditions
Figure 2: Percent changes in survival gaps, 1980–2014
Chart shows percent changes in income, education, and county socioeconomic condition-related survival gaps
reported in the literature reviewed. Each bar represents a row in the table. The vast majority of studies reported
widening survival gaps.
For more on the Health and Changes in the income–survival gradient differed across
Retirement Study see the income distribution. The life expectancy gradient
http://hrsonline.isr.umich.edu
increased sharply in households earning less than $60 000
per year, with the slope rising by 37% in men (from
2·5 to 3·4 years per log-point of income) and 77% in
women (from 1·4 to 2·5 years per log-point). However, the
gradient did not change for men and women in
households earning over $60 000 per year (figure 4).
In summary, the divergence of life expectancy for poor
and middle-income Americans since 2001 (figure 3)
reflects both changes in income distribution and a rise
in gradient between income and health, with the latter
a more important factor. Both distribution changes
and slope changes were non-linear and specifically dis­
advantaged the poor (figure 4). From 2001 to 2014, poverty
deepened in the USA; at the same time, poverty emerged
as an increasingly important risk factor for mortality in
American adults.
The studies discussed above presented period
(ie, repeated cross-sectional) estimates of survival which
might underestimate—or overestimate—changes in
survival gaps across actual birth cohorts. A cohort
perspective has the advantage of capturing a population’s
full exposure and health history from childhood,
mapping health more closely to lived experiences
(panel 1). The challenge in assessment of trends across
birth cohorts is that age-specific mortality rates can be
definitively known only for those ages observed. Cohort
life expectancy estimates have to be projected from
models unless all members of the birth cohort have died.
Waldron27 used Social Security data on lifetime income
and mortality to assess age-specific mortality rates of
men with incomes above and below the median for
cohorts born between 1912 and 1941 (who reached
1480 www.thelancet.com Vol 389 April 8, 2017
60 years of age between 1972 and 1998). The relationship
between income and age-specific mortality strengthened
across birth cohorts (figure 5). Although the relationship
between income and mortality could be expected to be
attenuated at older ages because of survivorship bias,
income-related mortality odds ratios rose across birth
cohorts for all age groups observed. Based on projected
future trends in age-specific mortality rates, Waldron27
estimated that the gap in male life expectancy at age
65 years between the top and bottom half of the income
distribution increased from less than 1 year for men
born in 1912 to more than 5 years for men born in 1941
(table).27
Using similar calculations, a 2015 report7 by the
National Academies of Sciences, Engineering, and
Medicine (NAS) estimated survival curves for the 1930
and 1960 birth cohorts based on data from the Health
and Retirement Study. Survival was assessed by quintile
of long-run earnings (averaged from ages 41 to 50 years).
The study7 projected that life expectancy at 50 years will
stagnate for men in the poorest quintile and decline for
women in the bottom two quintiles (figure 5). As a result,
the gap in life expectancy at age 50 years between the top
and bottom income quintiles was projected to increase
from 5·1 years for men born in 1930 to 12·7 years for
men born in 1960; the comparable figures for women
were 3·9 years and 13·6 years. The gap in cohort life
expectancy between the richest and poorest 20% of
Americans is projected to increase by nearly a decade in a
single generation.
Estimates of cohort life expectancy should be
interpreted cautiously because old-age survival has not
yet been observed in recent birth cohorts, necessitating
extrapolation from mortality rates observed at younger
ages; for example, the NAS study7 projected cohort life
expectancy at age 50 years even though no members
of the 1960 cohort had reached that age by end of
follow-up. Nevertheless, these two cohort studies7,27
highlight the possibility that a slow-moving disaster
might be unfolding for the health of lower-income
Americans who entered the labour market after the
post-World War 2 boom and have spent their working
years in a period of rising income inequality. The
inscrutability of trends in cohort life expectancy gaps
while they are emerging should not lower our vigilance.
Differences in mortality across birth cohorts can still be
documented at younger ages (figure 5). More importantly,
policies could potentially be designed that mitigate the
very large survival deficits emerging for recent cohorts of
lower-income Americans (figure 5).
Growing gaps in survival by education: a review
Survival gaps by educational attainment have also
widened in the past three decades.28–34,44–54 Although
estimates differ depending on groups compared, time
period analysed, ages at which mortality was assessed,
and whether studies adjusted for composition changes,

Panel 1: Challenges in measuring trends in health inequalities
Studies differed with respect to data sources, indicators of
socioeconomic status and health, and statistical measures used
to summarise health inequalities.
Data sources
Studies have used three types of data: (1) nationally representative
population-based surveys such as the National Health Interview
Survey and National Longitudinal Mortality Study, which collect
self-reported education and income data at a single point in time
and have been linked to subsequent national death records;29,30
(2) income histories from individuals’ tax records that have been
linked with death records maintained by the Social Security
system;6,7,26,27,38 and (3) US death certificates, which have included
information on educational attainment since 1989, and can be
combined with Census data to enable assessment of survival
trends by education.31,33,34 Long-run trends dating to 1960 have
been analysed using county-based measures of socioeconomic
status.35,36,39
Measures of socioeconomic status
Studies have used income, education, and area-based
measures—each of which has its limitations. Incomes vary
across the life course. Earnings measured at a single point in
time might be a poor reflection of lifetime earnings, particularly
for retirees, and are subject to random fluctuations which
attenuate the relationship between socioeconomic status and
health. Health shocks can also negatively affect earnings,40
inflating the cross-sectional association between income and
health.
Measurement of socioeconomic status by educational
attainment overcomes some of these limitations, because
schooling is largely determined by age 25 years and does not
fluctuate. However, the coarseness of education data can make
inferences difficult. For example, no clear ordinal ranking for
post-university education exists, so most studies lump together
all university graduates. Simply counting years of schooling
ignores important variation in the quality of education that
might be associated with both earnings and health.
Self-reported income and education data are also subject to
reporting biases, which could be substantial.41 A key threat to
validity is compositional change within education categories
over time. In 1920, failure to complete high school was
common among people who might today be considered as
middle class; over time, it has become a marker of very low
socioeconomic status. Hence, analyses that use a static measure
of educational attainment to indicate socioeconomic status
might find a decline over time in life expectancy, even if no real
change in socioeconomic status-based differences in survival
has occurred.42 Researchers have addressed this issue by
randomly reallocating people across education categories to
equalise the distribution of educational attainment across time
periods.27,29,30,43 Unfortunately, this approach is not guaranteed
to eliminate bias.
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To overcome these limitations, studies have increasingly
analysed income as observed in tax records or Social Security
data.6,7,26,27 Such data reduce reporting bias and can be averaged
across many years to minimise the effects of year-to-year
variation. A so-called washout period (eg, 2 years) can be
included to reduce the influence of reverse causality from
health shocks. Perhaps most importantly, health outcomes can
be assessed across quantiles of the income distribution,
avoiding the compositional complications of educational
attainment or fixed income brackets. To the extent that a
person’s rank in the income distribution reflects unobserved
factors that might be correlated with health, assessment of
secular trends within income quantiles holds these factors
constant. At the same time, health trends for specific income
quantiles might reflect both changes in income for that
quantile as well as changes in the relationship between income
and health.
Measures of health and longevity
Studies assessing trends in survival have made different
choices regarding the age groups included—eg, 25–65 years,35
35–75 years,26 40–76 years,6 and 50 years and older.7 Due to
differences in age-specific mortality rates, these choices can
substantially influence results. Typically, the association
between low socioeconomic status and mortality is strongest
on a relative scale at younger ages, but absolute differences
are greatest at older ages when background mortality is
higher. Most studies report age-standardised or age-adjusted
mortality rates. Many report period life expectancy,
combining age-specific mortality rates to create a period
survival curve from which life expectancy can be estimated.
Period versus cohort measures
Period survival measures (eg, life expectancy in 2015) are the
basis for international comparisons and are useful to identify
the effect of exposures that simultaneously affect people of all
ages, such as famine. However, period measures might miss
important transformations in the risk faced by different birth
cohorts—for example, AIDS caused particularly high death rates
among people who were sexually active during the first decades
of the epidemic.
Several studies compared survival across different birth cohorts
rather than across different periods.7,44–47 Although cohort
approaches more accurately describe the fate of specific
populations, the full cohort survival curve can only be assessed
after all members have died. Hence, only trends in non-elderly
mortality are observed for recent birth cohorts.27 Cohort life
expectancy can be projected by extrapolating current survival
patterns and imputing future age-specific mortality rates,7,27 but
such estimates should be interpreted with caution, as they are
projections of future events rather than observed estimates.
 Series
A Men
0·4
Change per year in expected age at death (years)
0·3
0·2
0·1
0 standardised premature mortality (ages 25–64 years)
–0·1
0 5
Mean household income 30
($1000s)
B Women
0·4
Change per year in expected age at death (years)
0·3
0·2
0·1
0
–0·1
0 5
Household income ventile
Mean household income 27
($1000s)
Figure 3: Changes in life expectancy across the income distribution, 2001–14
Figure shows average annual change in life expectancy by household income
ventile. Shaded areas show 95% CIs. Reproduced from Chetty et al,6 by
permission of the American Medical Association.
the studies we reviewed were broadly consistent in
pointing to widening survival inequalities by educational
attainment (table, appendix).
Combining data from death certificates and US Census
data, Olshansky and colleagues31 compared period life
expectancy at age 25 years for Americans with a university
education (undergraduate; ≥16 years of education) versus
Americans with less than a high-school education
(<12 years of education; table). From 1990 to 2008,
education-related life expectancy gaps increased by
0·8 years for men and 2·6 years for women. Trends
varied by race ethnicity, with life expectancy gaps
widening by more than 8 years among white people,
about 4 years among black people, and holding steady
among Hispanic people. During the 1990s and early
2000s, life expectancy outright declined by 5·3 years for
women and 3·4 years for men among white people with
fewer than 12 years of schooling.31
1482 www.thelancet.com Vol 389 April 8, 2017
Using a smaller sample enabling analysis of trends
beginning in 1980, Ho and Fenelon28 compared life
expectancy at age 50 years for white university-educated
(≥16 years of education) Americans versus white
Americans with a high-school education or less (≤12 years
of education; table). Between 1980 and 2006, the gap in
life expectancy increased by 1·1 years (26%) for men and
2·1 years (84%) for women.28
Several other studies reported education-specific trends
in mortality rates that were consistent with these
findings. Ma and colleagues33 assessed trends in age-
from 1993 to 2007, by educational attainment (0–12 years
of education, 13–15 years, and ≥16 years) as reported in
10 15 20 death certificates. Premature mortality fell by 34% for
60 101 683 men with a university education and by just 5% for men
with a high-school education or less. For university-
educated women, premature mortality fell by 29%, but
increased by 11% in women with 12 years of schooling or
fewer.33 The difference in mortality risk associated with
low (vs high) education increased by 14% in men and
55% in women (table).33 Focusing on white Americans
aged 45–84 years, Montez and Berkman32 found that
between 1986 and 2006, age-standardised mortality fell
by 22% among university-educated men and by 8%
among men with fewer than 12 years of schooling;
mortality fell by 11% in university-educated women but
increased by 21% in women with fewer than 12 years of
schooling. Case and Deaton34 and Cutler and colleagues54
also report widening gaps in mortality rates by
educational attainment.
10 15 20
Changes in the composition of education groups (eg, the
54 95 653 shrinking proportion of Americans failing to complete
high school) might confound analyses of trends in
education-based health inequalities (panel 1).30 Studies
correcting for composition shifts have nonetheless found
growing gaps. Meara and colleagues29 found that between
1990 and 2000, mortality at ages 25–84 years fell for people
with at least some university education, but not for those
without higher education; the education gap in life
expectancy at age 25 years increased by 1·6 years (table).
Adjusting for composition, Hendi30 found that the gap in
life expectancy between white women who completed
university and those that did not complete high school
increased by 2·2 years from 1991 to 2005; however, the gap
for white men rose by only 0·1 years (table). Life expectancy
declined by 0·7 years for white women with fewer than
12 years of schooling.30 Although changes in composition
played a role—explaining 26% of the widening gap in
women and 87% of the widening gap in men by
one estimate30—the studies29,30,52 reviewed nevertheless
found consistent evidence of widening survival
inequalities, even after adjustment for composition.
Several studies have assessed the education–survival
gradient across successive birth cohorts, rather than
time periods.44–47 Masters and colleagues45 found that
the widening gap in mortality across education groups
 Series

A B
0 Women
0·4 Men

Change per year in life expectancy (years)

–5
Change in household income (%)

0·3

–10

0·2
–15

0·1
–20

0
–25
0 20 40 60 80 100 <5 10 25 50 100 250 500 1000
Household income percentile Household income ($1000s)

C Men D Women
2001–02
2013–14
90 90
Expected age at death (years)

87

87
84

81
84

78

75 81

<5 10 25 50 100 250 500 1000 <5 10 25 50 100 250 500 1000
Household income ($1000s) Household income ($1000s)

Figure 4: Decomposition of trends: changes in life expectancy across the income distribution, 2001–14
Graphs show (A) percentage change in household income from 2001 to 2014, by income percentile, for men (similar trends were observed for women);
(B) the average annual change in life expectancy by household income category over the period 2001–14 (whereas figure 3 shows changes by income percentile);
and the income–life expectancy gradient in 2001–02 and 2013–14 for men (C) and women (D), shown as a kernel-weighted moving average. Household income is
expressed in 2012 US$, based on US tax records, and is presented on a log scale. In (B), income categories were defined in 0·5 log-point bins: 8·5, 9·0, 9·5, …, 14.0;
male datapoints are offset for visualisation purposes. Differential changes in life expectancy by income percentile were the result of both (A) falling incomes among
the poor and (B–D) a steeper gradient between income and life expectancy. Data are from Chetty et al.6

was attributable entirely to cohort rather than period groups (table, figure 2, appendix). The trends identified
exposures, consistent with the theory that trends in have origins that precede 1980. Studies have identified
survival inequalities are driven primarily by differences widening survival gaps in earlier decades not covered by
across—rather than within—individuals.45 The gains in our literature search. Among white men aged 25–64 years,
survival enjoyed by white men and women with at least a the mortality rate ratio between the top and bottom
high-school education were not experienced by black income categories rose from 1·8 in 196055 to 2·2 in
men and women, suggesting that the health benefits of 1973–78.56 A study57 comparing 1960 and 1986 mortality
education might be modified by factors associated with rates by income and education found a similar pattern. By
race and ethnicity.45 Studies by Everett and colleagues44 contrast, a study35 of non-elderly mortality by county
and Krueger and colleagues47 also identified increased income quintile identified narrowing survival inequalities
education–mortality hazard ratios in more recent between the mid-1960s and 1980. Consolidation of a
cohorts. A challenge in these studies is that more recent longer, internally comparable individual-level time-series
birth cohorts are observed only at younger ages when the and decomposition into longer-run trends are important
education–mortality gradient is typically strongest (eg, avenues for future research.
figure 5); separation of cohort effects from age-related Finally, education and income levels are not simply
effect modification in a regression context without proxies for a single underlying construct. Rather, they are
additional assumptions is difficult. distinct factors that might be related to health in different
Taken as a whole, the literature suggests a pattern of ways and which, if causally related, would imply different
widening gaps in survival across income and education interventions.

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 Series

health might be increasing over time for reasons

A
2·0 60–64
independent of changes in the labour market value of
65–69 education. Increases in education might have facilitated
70–74
Mortality in low-income vs high-income men

the adoption of and adherence to healthful behaviours,

75–79
1·8 such as condom use,61 smoking cessation,62 and
medication compliance,63 as new health information and
1·6 interventions have become available.64 Studies of the so-
(odds ratio)

called sheepskin effect—the benefits of receiving a

diploma over and above the effect of a single year of
1·4 schooling—suggest that both labour market and non-
labour market factors might explain the growing
1·2 association between education and survival.51 Another
possibility is that education, income, and survival are all
consequences of in-utero and childhood health exposures
1·0
1912 1916 1920 1924 1928 1932 1936 (which in turn bear the imprint of early-life socio­
Birth cohort economic circumstance).65,66
B With these comments on the relationship between
90 income, education, and health, we now turn to the
89
88 evidence for different mechanisms. Why have socio­
economic differences in health widened during the past
85
40 years? We consider specific causes of death and
Expected age at death (years)

83 individual-level risk behaviours, often described as

82
80
80
78 78
77
77
76
75
70
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4
1930 1960
Birth cohort
Figure 5: Widening income-related inequalities in survival across birth cohorts
(A) Excess mortality (odds ratio) associated with lifetime income in the lower (vs upper) 50% of the income
distribution is shown at different ages for men born in 1912–38. Birth cohorts were grouped into 3-year intervals;
the start of the interval is labelled on the horizontal axis. The association between income and mortality increased
across birth cohorts for all observed age groups. Data are from Waldron (2007).27 (B) The projected life expectancy
at age 50 is shown for 1930 and 1960 birth cohorts, by income quintile—Q1 (poorest) to Q5 (richest). Life
expectancy is displayed as expected age at death, conditional on reaching age 50. Estimates for 1930 cohort are
based on observed and projected age-specific mortality rates; estimates for 1960 cohort are based entirely on
projections. Underlying data for these projections come from the Health and Retirement Study. Projections
presented are for men; similar divergence in life expectancy by income was projected for female birth cohorts.
Cohort life expectancy for the bottom two quintiles of the 1930 birth cohort was 76·6 years (Q1) and 77·2 years
(Q2). Data are from the National Academies of Sciences, Engineering, and Medicine study.7
Education is a causal determinant of both earnings and
health,58,59 and evidence suggests that both of these
relationships have strengthened over time. Economic
returns to higher education have increased in the past
40 years, due to a phenomenon described by economists
as skill-biased technical change.60 New technologies,
chiefly the rise of computers in the office and factory
floor, have increased the wage returns to education-
related expertise, while reducing demand for less skilled
clerical labour. Divergence in earnings across education
groups is one reason for the growth in income inequality
and might be the cause of growing health inequalities. At
the same time, the relationship between education and
proximate causes, as well as more fundamental or distal
causes that might give rise to changes in the distribution of
specific risk factors and in turn to widening health gaps.67
Proximate factors mediating widening
health gaps
Evidence on mechanisms for widening health gaps
comes from cause-specific mortality data—available
Q5 from death certificates—and studies on the evolution of
individual-level risk factors across different socio­
economic groups.
A leading hypothesis is that widening mortality gaps
result from differential trends in individual-level risk
factors. Research has focused on the triad of risk factors
central to clinical recommendations for the prevention
and control of cardiovascular and metabolic disease in
the USA: do not smoke, maintain a healthy weight, and
adhere to prescribed medication.63,64 Smoking prevalence
has fallen much faster among well-educated and higher-
income Americans than among lower socioeconomic
status Americans,28 leading to the emergence of
substantial differences in the burden of smoking-related
disease.28,54 A similar phenomenon is emerging with
obesity.68 But how much of the widening survival gap
do these risk factors explain?
Trends in causes of death provide some insight. Across
birth cohorts, education gaps in heart disease and lung
cancer mortality increased, but gaps did not widen for
non-preventable cancers, suggesting the importance of
changes in modifiable risk factors and use of medical
care.45 Between 1968 and 1998, male cardiovascular
mortality declined faster in high-socioeconomic status
counties than in low-socioeconomic status counties.36
The absolute gap in diabetes mortality between university
graduates and people with a high-school education or

1484 www.thelancet.com Vol 389 April 8, 2017


less increased from 1993 to 2007.33 Mortality due to heart
disease, stroke, and cancer declined in all education
groups, yet absolute differences between groups
remained approximately constant, thus increasing
relative differences.33 Among white women without a
high-school education, mortality from smoking-related
causes (including lung cancer and chronic lower
respiratory disease), diabetes, and Alzheimer’s disease
increased between 1986 and 2006, accounting for much
of the divergence in mortality in this category relative to
higher education groups.69
Further evidence can be found from trends in risk
behaviours. Smoking patterns have diverged, with an
increasing burden among people with the least
education.28 However, one study54 found that divergent
smoking rates were not sufficient to explain the widening
mortality gap. Another study28 found that smoking trends
explained 25–50% of the growth in the life expectancy gap
across education groups for women, but did not contribute
to widening survival gaps in men. Additionally, at the
county level, increases in the association between
mortality and county income from 1980 to 2002 were
attributed in part to changes in mortality unrelated to
smoking.35,39 Among adults, trends in obesity and
management of hypertension and cholesterol have been
similar across education groups over time, suggesting
that these factors do not substantially mediate the changes
in survival inequalities. Furthermore, the education–
mortality gradient increased over time—even after
adjusting for these individual-level risk factors.54 In sum,
differential smoking trends by socioeconomic status are
an important part of the explanation, but do not tell the
whole story. Obesity has not contributed substantially to
historical trends, although it might lead to future gaps in
survival.70
Substance abuse and addiction might also be
contributing to widening health inequalities. Ma and
colleagues’ 2012 analysis33 of premature deaths in
26 states between 1993 and 2007 concluded that the
differential increase in accidental deaths for people with
12 years of schooling or fewer (relative to university
graduates) was responsible for 23% of the total increase
in the all-cause-mortality gap among women and 49% of
the total increase among men. Many of these deaths
were attributable to poisoning by prescription drugs,
presumably mostly opioids.
Case and Deaton34 found that between 1999 and 2013,
all-cause mortality in the USA among white, non-Hispanic
adults aged 45–54 years fell from 235·1 to 178·1 deaths per
100 000 person-years in university-educated adults, but
increased from 601·4 to 735·8 deaths per 100 000 person-
years in those without higher education—a 52% increase
in the education-based mortality gradient in just 14 years.34
During this period, deaths from poisonings increased by
four times, leap-frogging deaths due to lung cancer in this
age group. The increase in deaths from poisonings,
suicide, and liver disease (plausibly intravenous drug-
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Series
related or alcohol-related) together accounted for half of
the total increase in mortality in adults with a high-school
education or less.34
Because abuse of alcohol and of prescription or illicit
drugs and self-harm behaviours affect morbidity as well
as mortality, these mortality trends are probably only the
most visible signal of larger trends in chronic physical
pain, mental illness, and addiction. Indeed, Case and
Deaton34 note very large increases in poor physical health
days (28%), poor mental health days (25%), and the
proportion of people unable to work because of disability
(49%) among middle-aged white adults. The rise in
adverse coping behaviours among Americans of low
socioeconomic status—namely, abuse of controlled
substances including tobacco, alcohol, and prescription
drugs, as well as self-harm—should thus be seen in the
context of growing epidemics of disability, chronic pain,
and multiple morbidity71 amidst shrinking capacities
to cope.72
Rising mortality due to adverse coping behaviours
explains a substantial portion of the divergence in
survival chances for low-income and poorly educated
Americans since the 1990s.
Distal mechanisms for widening health gaps
Distal mechanisms that underlie changing health
inequalities are difficult to pin down.53 However, an
exclusive focus on individual-level behaviour as a
mechanism would miss the larger structural factors that
might be driving these trends. We highlight several
potential explanations for why health inequalities have
increased in an era of rising income inequality:
(1) differential adoption of technological innovations in
medicine as well as non-medical health inputs (eg,
information about complex health risks and preventive
behaviours), with differences driven both by diffusion
behaviour and by cost barriers; (2) increasing geo­graphical
segregation that creates inequalities in access to salutary
health amenities; (3) reduced economic mobility leading
to increased persistence of poverty for low-income
Americans; (4) the repercussions of rising incarceration
rates; and (5) the erosion of public subsidies for health
insurance and other health inputs, and increasing
exposure to market prices. These distal hypotheses are not
intended to be exhaustive. However, they highlight
potential reasons for the changing relationship between
income and health at the bottom of the income
distribution. Although a full investigation is beyond the
scope of this paper, we note that several of these
hypotheses could be linked indirectly to growing income
inequality higher in the distribution and its effect on
technological innovation, housing markets, economic
opportunity, and political appetite for redistributive
policies.
Innovations in medical care and new information on
health risks might lead to widening health inequalities if
high-income or well-educated Americans are the first to
 Series
adopt new healthful technologies and behaviours.63 Health
gaps might shrink as innovations fully diffuse, but could
persist with continuous innovations. Several factors are at
play here. First, education and income might improve
people’s ability to consider and incorporate new
information on health risks (or prevention strategies) into
their decision making, from smoking to medication
adherence, leading to faster adoption.64 Second, the
non-health benefits of many risk behaviours—eg, the
temporary relief of stress, pain, and hunger afforded by
tobacco, opioids, and calorie-dense, nutrient-poor foods—
might be valued more by low-income Americans who face
more of these stressors. Third, if medical innovation
increases the availability of effective but costly
interventions (and if these interventions are not fully
subsidised), then differences in ability to pay might lead to
widening disparities in access. A similar argument applies
to other health inputs, such as the increased availability of
healthy, yet costly, food options. Fourth, not all innovation
is healthful, and even health-promoting innovations such
as pain relievers might be marketed for abuse. High-
socioeconomic status Americans might have more
options to mitigate exposure to new health risks.
The graded diffusion of health inputs by socioeconomic
status is not new. For example, in the early 20th century,
child mortality in the USA declined much faster among
children of professionals than among children of labourers,
with the discovery of germ theory and hand-washing
information campaigns.73 However, the importance of
differential adoption has probably inc­reased over time with
the rapid growth in accurate health information and
effective medical technologies and the relative importance
of these innovations for health compared with earlier eras.
Studies have attributed approximately half of all life
expectancy gains since 1950 to medical innovations,74
including statins,75 antihyper­tensives,76 and coronary care
units,77 with further gains attributable to changes in health
risk behaviours such as smoking and diet spurred by the
diffusion of new scientific knowledge.77 Although many of
these innovations pre-dated the period of study, the 1980s
and 1990s were a period of rapid diffusion, with large
declines in smoking prevalence and increases in use of
medication to control cholesterol and hypertension. The
implications for health inequalities depend on the nature
of the innovation. New treatments for diabetes and HIV led
to differential uptake by educational attainment that
exacerbated inequalities.63 However, classes of anti­
hypertensives that simplified compliance led to widespread
uptake and reduced usage gaps.78,79
A second potential explanation for rising health
inequalities is the increasing geographical segregation
of high-income and low-income Americans, resulting
in differential access to neighbourhood-level health
amenities. Income segregation across school districts in
the USA increased by 15% between 1990 and 2010, and
within-district segregation across schools increased by
40%.80 Factors contributing to rising segregation include
1486 www.thelancet.com Vol 389 April 8, 2017
the increased concentration of economic growth in
specific regions, the rise in housing prices during the
1990s and early 2000s, which has priced many Americans
out of specific geographical housing and rental markets,
and widening income inequality itself. Residential
segregation might translate into health inequalities
through a range of social and environmental exposures
including crime, gun ownership, access to green
space and supermarkets, air pollution, social capital,
community norms, and local policies that affect
population health. Several studies6,35,36,81 have identified
rising inequalities in health across geographical units
such as US counties, with richer counties pulling away
from the rest.
A third possible pathway is the reduction in economic
mobility for low-income Americans, which could lead to
the hardening of class boundaries and to the persistence
of poverty both within and across generations.82,83 Because
current earnings are correlated with future earnings,
rising income inequality implies even larger gaps in
future income. Furthermore, this correlation might have
increased over time with growing inequalities in returns
to on-the-job experience in higher (vs lower) skilled
occupations.84 To the extent that health decisions are
made with an eye to the future, increasingly bleak
prospects for economic mobility might lead to reduced
investment in health and divergence in health behaviours
across income groups. Economic insecurity and
vulnerability, including anxiety about the possibility of
catastrophic health expenses,9 might also contribute to
stress with direct health consequences.85 The rising
burden of disease associated with substance abuse and
self-harm among low-income Americans might reflect
lower future optimism and efforts to cope with stressors
including economic vulnerability. In turn, disinvestments
in health—including use of addictive substances—can
reduce future productivity and earnings.86 The rising
epidemic of opioid addiction, as well as other adverse
coping behaviours, might signal the emergence of a
21st century health-poverty trap, a negative feedback loop
between poverty and poor health.
The wave of incarceration that began during the 1970s
is a fourth possible mechanism underlying the widening
health inequalities between the poor and middle class.
As discussed in detail in a companion paper87 a large
proportion of poor men, especially black men, are current
or former prisoners, and incarceration appears to inflict
substantial economic and health damage on prisoners,
their families, and their communities.88
A final potential mechanism is the increased exposure
of Americans to the prices of health inputs.
Technological change has increased the armamentarium
of effective medication and procedures. Concurrently,
the proportion of medical costs covered by insurers has
fallen over time, with rising deductibles and co-
payments shifting more of the costs of care onto users.
Although some economists and policy leaders have

promoted user fees as a way to dampen health-care cost
growth, cost sharing—ie, passing more of the costs for
a given service on to patients—discriminates by ability
to pay. Since the early 2000s, health spending for
wealthier Americans has soared, whereas expenditures
have risen modestly for the middle class and actually
fallen for those with low incomes.89 Medical spending
in the USA was historically highest among the poor,
who have the greatest medical need and whose care is
subsidised by Medicaid. However, the income–
spending gradient has now reversed—a phenomenon
known as the Inverse Care Law.90 Although the health
implications of greater cost sharing are not fully
understood, cost sharing might possibly have led the
poor to avoid needed services, which might have
contributed to the widening health gap between poor
and middle-income Americans. Whether the rising
inequalities in medical spending will translate into
even more divergent health outcomes is unknown.
Impoverishing medical expenses9 could also lead to
worse health outcomes—a health-poverty trap driven
by medical cost. Price exposure to health inputs extends
beyond medical care, to include healthy food, good
childcare, safe neighbourhoods, and the wide range of
social determinants of health that are—at least in
part—priced in the market.
Exposure to prices of health care and other health inputs
can be mitigated—and has been mitigated in the past—
through public subsidies. For instance, in the early
20th century, massive improvements in the health of low-
income Americans were achieved through control of
infectious disease via publicly funded centralised water
filtration and purification.91 Elites were willing to fund
expensive water infrastructure and other public goods to
avoid epidemics of typhoid and cholera that could spread to
them.92 Although investments in the control of non-
communicable diseases cannot be motivated by fear of
contagion,93 investments in the health of the poor might
nevertheless be driven by political demands. On a global
scale, demands for justice and equality led to the
commitment to “health for all” at the 1978 International
Conference on Primary Health Care in Alma Ata,
Kazakhstan. In the USA, widespread mobilisation for
social justice that coalesced during the Civil Rights
Movement led to the introduction of Medicare94 and
Medicaid (the health insurance programme for the poor),95
racial integration of hospitals,96 public investments in
community health centres,97 early childhood investments
such as Head Start,98 and other Great Society and War on
Poverty programmes. This ensemble of reforms led to mid-
century gains in survival among poor Americans, especially
black Americans. Comparison across high-income
countries reveals evidence that social protection policies
mediate the effect of macroeconomic fluctuations on
health of the vulnerable—eg, reducing incidence of
suicides.99 Welfare-state expansions have been associated
with life expectancy improvements and might explain, in
www.thelancet.com Vol 389 April 8, 2017 1487
Series
part, the large health gaps between the USA and Europe.100
At the same time, health inequalities have persisted—and
grown—even in the most redistributive northern European
countries.101 Exploration of the effects of specific health and
social policies on health inequalities is a key area for future
research.
More recently, widespread dissatisfaction with the
health-care financing system in the USA triggered
passage of the Affordable Care Act. As discussed in detail
in another paper102 in this Series, that legislation has
reduced gaps in insurance coverage, although it remains
to be seen whether the Affordable Care Act will stop the
growth in income-related health inequalities. The future
of the Affordable Care Act—and access to health
insurance for millions of low-income Americans—is
now in question with the transition in 2017 to a
Republican-controlled government that has promised to
dismantle the legislation.
Future areas of research
In light of existing literature, we highlight several
important areas for future research on this topic in
panel 2.
Panel 2: Areas for future research
• Further characterisation of the burden of disease associated with poverty and limited
economic opportunity in the 21st century, including—but not limited to—epidemics
of addiction and self-harm.
• Assessment of trends in socioeconomic inequalities in morbidity. Most of the
literature has focused on mortality. Existing behavioural risk factors such as smoking,
drinking, and medication adherence do not fully capture the increased burden of
disease among the poor. Chronic pain and mental health issues are key
under-researched aspects of disease burden.34
• Research into the implications of increased geographical segregation by
socioeconomic status, including the increased sorting of people by economic
opportunity and implications for health inequalities.
• Investigation of geographical predictors of health among the poor, with high levels of
area-related heterogeneity shown in recent research.6
• Assessment of the role of early-childhood exposures in explaining widening health
gradients. Although a growing body of literature points to childhood health as an
origin of adult disease, it is notable that mortality gaps are widening among ageing
baby boomers born into a post-World War 2 society that was (at least for white
Americans) more equal than current society. Nevertheless, a full account of childhood
exposure could unearth alternative explanations for the divergence in adult health.
• Research into the mediating role of public institutions and social programmes and
their capacity to weaken the link between income, education, and health.
• Evaluations of policies and programmes using credible causal designs (eg, randomised
trials and natural experiments) to understand policy options to reduce the strong
association between poverty and poor health.
• Evaluations of interventions to alleviate poverty and reduce income inequality, with
particular attention to which types of interventions—eg, tax credits, job training,
employment programmes—are the best for health.
• Evaluations of interventions to reduce the financial burden of ill health, including the
Affordable Care Act and other policies designed to increase access to health coverage,
as well as health systems reforms that might reduce access to care.
 Series
Our review should be interpreted in light of its
limitations. We reviewed the extant literature on trends
in socioeconomic inequalities in health in the USA
over time. Although we have discussed some potential
reasons for these changes, this literature is by nature
descriptive and does not support inferences about the
effects of specific policy interventions. Interventions to
prevent or mitigate the 21st-century burden of disease
associated with poverty, including epidemics of addiction
and self-harm, are needed. Further research using robust
causal designs (eg, randomised trials and natural
experiments) is urgently needed to better understand
how we can halt and close the widening gap in life
chances between lower-income and upper-income
Americans. We emphasise further the importance of
more finely grained data on morbidity, risk factors, and
causes of death to identify opportunities for intervention.
Conclusion
The rise in income inequality in the USA in 1980–2015
has coincided with widening inequalities in health and
longevity. Not only do the poor have lower incomes, they
increasingly live shorter lives than do higher-income
Americans.
Growth in income inequality is most visible in the
soaring incomes of top earners. By contrast, rising health
inequalities have been observed across the full income
distribution and, in recent years, chiefly among low-
income and middle-income Americans. Whereas the top
1% of earners take home a larger share of total earnings
than at any time since the Great Depression, their health
outcomes still represent just 1% of the population.
Changes in survival gaps during the period 1980–2015
are not simply a reflection of rising life expectancy
among top earners.
Our review attributes rising survival inequalities to
two factors. First, since 2001, real incomes have declined
for poor and middle-income Americans; these income
losses, experienced by those who can least afford them,
might very well have implications for health and
longevity. Second, the association between income and
life expectancy has become stronger over time. Factors
including technological innovation, increased geo­
graphical segregation, mass incarceration, reduced
economic mobility, and increased exposure to prices
might have contributed to a steepening gradient between
income and health and to the increasing importance of
poverty as a risk factor for poor health. Gaps have
widened in causes of death linked to smoking and other
adverse coping behaviours, although the aggregate
trends have yet to be explained fully. Importantly, the
increased correlation between health and income might
contribute to negative feedback loops, making mobility
along either axis more difficult. Interventions to decouple
income and health—in addition to interventions targeted
solely to improving health and economic prospects—
might be needed.
1488 www.thelancet.com Vol 389 April 8, 2017
Although these explanations are necessarily speculative,
understanding the reasons behind rising health in­
equalities is of crucial importance. Estimates of cohort
life expectancy project that the gap in life expectancy
between the richest and poorest quintiles will have
increased by nearly a decade within a single generation.7
Mitigation of these gaps might still be possible. Public
investments in the health of low-income Americans have
led to large health improvements in the past. New
investments in the health of poorer Americans might be
necessary to avoid a 21st century health-poverty trap and
to ensure that low-income Americans have an equal
opportunity to lead long, healthy lives.
Contributors
All authors contributed equally to the writing of the manuscript.
Declaration of interests
We declare no competing interests.
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