Income Inequality In addition to overall area-level income, the distribution of income and wealth...
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In addition to overall area-level income, the distribution of income and wealth within an area can also influence the delivery of health services. Income inequality, typically measured as the Gini index, where 0 indicates the most equal income distribution and 1 the most unequal, is at an all-time high in the United States and is one of the highest among similar economies (DeBacker, Heim, Panousi, Ramnath, & Vidangos, 2013; OECD, 2011). Although evidence from other countries is mixed on whether or not the gap between the rich and poor erodes the health of populations (Deaton & Lubotsky, 2009; Kahn, Wise, Kennedy, & Kawachi, 2000; McGrail, van Doorslaer, Ross, & Sanmartin, 2009; Subramanian & Kawachi, 2004; Wilkinson & Pickett, 2006), the findings on income inequality's negative effect on health, typically measured as mortality or as self-rated health, is most robust for the United States. And among studies that do find an effect between income inequality and health, across all nations income inequality appears to be most detrimental to the poor (Diez-Roux, Link, & Northridge, 2000; Subramanian & Kawachi, 2003; Wagstaff & van Doorslaer, 2000).
We know less as to whether income inequality affects equity in health care delivery and whether a reformed U.S. health system with near-universal access may attenuate the effects of area-based social disparities. Indeed, a study comparing pre-ACA United States and Canada suggests that the null finding on income inequality on health in Canada may be due to Canada's lower income inequality and universal coverage (Ross et al., 2000). A few studies to date have implicated high income-related inequalities as impinging primary care access (Chen & Escare, 2004; Macinko, Shi, Starfield, & Wulu, 2003).
In contrast, areas with high income inequality appear to favor the use and diffusion of expensive specialty care (van Doorslaer, Koolman, & Jones, 2004). This may be because high income inequality areas may attract specialists who are more likely to be located near academic centers. This framework embraces a market forces perspective, or a neomaterialist view, advanced by Lynch and others that income inequality promotes availability of health services, spurred by the demands of the wealthy (Lynch, 2000). The competing psychosocial view, advanced by Wilkinson and Pickett (Wilkinson & Pickett, 2006), postulates a more patient-centered and patient-provider interaction lens—that is, in our stylistic interpretation, income inequality stigmatizes patients, lessens patient agency to seek resources or information to better navigate health services and to make the best choices to improve their quality of their care. In high inequality areas, clinicians may also differentially value patients owing to the provider's perceived hierarchies by class, gender, and race in the places where they practice. Access to health services would be higher in more egalitarian, socially cohesive areas, as patients are not stigmatized and clinicians may not be discriminating based on the patient's socioeconomic position. Supporting this view, Clarkwest found that higher state-level income inequality was associated with poorer health care quality (average adherence rate for twenty-two Center for Medicare and Medicaid Services [CMS] quality-of-care measures) and also found that health care quality does indeed mediate the negative association between the Gini index and life expectancy (Clarkwest, 2008). However, another study in the United States found that income inequality is only weakly associated with maldistribution of doctors and not associated with hospital bed distribution (Horev, Pesis-Katz, & Mukamel, 2004). In sum, there is still no clear understanding of the direction of income inequality's effect on health. In health care, the evidence base on income inequality's effect on health care is still new, but the direction appears to follow a plausible pattern in which income inequality is negatively associated with primary care and safety net services, but positively associated with more expensive specialty services.
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