NEW BOOK on Health, Medicine and Justice

Book CoverHealth, Medicine and Justice
Designing a Fair and Equitable Healthcare System

By Joshua Freeman, M.D.

Buy the book HERE at Amazon

Joshua Freeman is a leader in primary care, both as a practitioner and as an academic, being the Chair of the Department of Family Medicine at the University of Kansas Medical Center.

He has an excellent understanding of our disorganized health care system and of the social determinants of health and health inequities. He has studied extensively medicine and social justice, and shares his views through his blog.

This book brings to print the basis of his passionate activism in support of equitable health care for all.



Chapter 1:  Why Do We Have a Healthcare System?

Chapter 2:  The U.S. Healthcare System: Best in the World?

Chapter 3:  The Social Determinants of Health and Health Inequities

Chapter 4:  Impact of the U.S. Health System on the Health of the Public

Chapter 5:  Primary Care: The Essential Basis for an Effective Healthcare System

Chapter 6:  The Role of Medical Education in Perpetuating the Health System

Chapter 7:  Graduate Medical Education

Chapter 8:  Assessing Appropriate Healthcare: Sometimes the Best Thing to Do Is Nothing

Chapter 9:  The Role of Profit in U.S. Health Care

Chapter 10:  Solutions and Projected Outcomes




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Income Inequality: It’s Also Bad for Your Health

We know that living in a poor community makes you less likely to live a long life. New evidence suggests that living in a community with high income inequality also seems to be bad for your health.

For original article and interactive U.S. map, click on link:

A study from researchers at the University of Wisconsin Population Health Institute examined a series of risk factors that help explain the health (or sickness) of counties in the United States. In addition to the suspects you might expect — a high smoking rate, a lot of violent crime — the researchers found that people in unequal communities were more likely to die before the age of 75 than people in more equal communities, even if the average incomes were the same.

“It’s not just the level of income in a community that matters — it’s also how income is distributed,” said Bridget Catlin, the co-director of the project, called the County Health Rankings and Roadmaps.

Many factors besides inequality affect health, of course. How much people smoke, whether they are obese, and the safety of air and water, among many other factors, make a difference. But the effect of inequality was statistically significant, equivalent to a difference of about 11 days of life between high- and low-inequality places. The differences were small, but for every increment that a community became more unequal, the proportion of residents dying before the age of 75 went up.

The research on inequality at the county level is new, but existing literature suggests there are relationships between income inequality and life expectancy among countries in the world. “Inequality effects, over and above average income, are pretty well established,” said S.V. Subramanian, a professor of population health and geography at Harvard, who has studied the phenomenon. We know that inequality tends to concentrate income in fewer hands, creating more low-income households — and people in low-income households don’t live as long. But what causes the drop in life expectancy is debatable.

One theory is that while money does tend to buy better health, it makes a bigger difference for people low on the income scale than those at the top. That means that having fewer very poor people in a community will improve average health more than having fewer very rich people will diminish it.

But another, more sociological theory, has to do with the communities themselves. The researchers think that places where wealthy residents can essentially buy their way out of social services may have less cohesion and investment in things like education and public health that we know affect life span. There is also literature suggesting that it’s stressful to live among people who are wealthier than you. That stress may translate into mental health problems or cardiac disease for lower-income residents of unequal places.

The researchers measured inequality by comparing the incomes of people in a given place who earned the 80th percentile in the county with the incomes of those in 20th percentile. Then they measured life expectancy using a custom measurement they developed — it counts the “potential life years lost” in each community by measuring all those who died before the age of 75, and the age at which they died. So someone who died at age 70 would have five years of potential life lost. Then they adjusted the numbers according to how old people were in the county, so counties with more old people wouldn’t look sicker than counties that were younger. The study looked at only the average life span and not that of higher-income versus lower-income residents.

For every one-point increase in the ratio between high and low earners in a county, there were about five years lost for every 1,000 people. That’s about the same difference they observed when a community’s smoking rate increased by 4 percent or its obesity rate rose by 3 percent. Researchers said that inequality effect persisted even when they compared communities of similar average income and racial composition.

Here’s what that means in some real counties. The researchers compared the adjoining Park and Fremont Counties in Wyoming. Both have relatively small populations and are predominantly white. Both include parts of large national parks. But the Fremont inequality ratio is 4.6, compared with Park’s 3.6. And, in Fremont County, there are 13 years of potential life lost for every 1,000 residents, compared with only 7.5 in Park.


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Street Artist Banksy’s New Video


Banksy’s Gaza Kitten Is Shaming Your Internet Habits

By Claire Landsbaum

Banksy’s latest. Photo: Banksy

No one throws a guilt trip quite like Banksy.

Case in point: The street artist just released a two-minute video (see link below)  that shows him sneaking into Gaza to embellish the area’s bombed-out ruins. The video satirizes travel ads in typical heavy-handed Banksy style.

It also features three new pieces: a man knelt in grief, children using an Israeli guard tower as an amusement-park ride, and a kitten with an enormous pink bow. “A local man came up and said ‘Please — what does this mean?”” Banksy writes in the kitten’s caption. “I explained I wanted to highlight the destruction in Gaza by posting photos on my website —but on the internet people only look at pictures of kittens.” He isn’t subtle, but he gets his point across.

Photo: Banksy

Photo: Banksy



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Income inequality – not just low wages – is taking a toll on the health of American workers

“Income inequality” has already become a buzz phrase for the campaigns leading up to the 2016 elections. Likely candidates and pundits on both ends of the political spectrum have begun to talk about how fairness, social justice and—even after the implementation of the Affordable Care Act—the cost of health care insurance are contributing to the large and growing gap between the rich and poor.

February 26, 2015
by Mark Wheeler

But a commentary by researchers at the UCLA Fielding School of Public Health points out another disturbing impact of : its effect on people’s health. The article appears in the current online edition of the American Journal of Public Health.

It has long been recognized that, even beyond access to high quality health care, people’s income is a key factor in determining how healthy people are. But the commentary provides evidence that the degree of income inequality also can lead to a long list of health issues, including shortened life expectancy and poorer self-reported health status.

Dr. Linda Rosenstock, the report’s senior author, said lower- and sometimes middle-income wage workers often face additional workplace stresses that take a toll on their health—among them, lower pay, lack of paid sick leave, an inability to find full-time work, the need to work double shifts to make ends meet. Those challenges can lead to high levels of stress, exhaustion, cardiovascular disease, lower life expectancy and obesity, and the effects can easily trickle down to impact families and children.

“We interpret the evidence to find that income inequality is taking a toll on worker health,” said Rosenstock, a UCLA professor of health policy and management and the former dean of the Fielding School. “Low- and middle-income workers face stagnant wages and pressures from a changing work environment. These changes in the work environment changes—such as increasing job insecurity, work performed outside of a regular full-time contract, and having fewer workers to do the same amount of work—are taking their toll on a workforce.”

The gap between the rich and the poor has expanded significantly since 1980, when the top 5 percent of wage earners accounted for almost 17 percent of all incomes, according to U.S. Census Bureau data. In 2013, that segment of the population earned 22 percent of total income. The changes were even more dramatic for those at the highest end of the income ladder, the top 1 percent and even the top one-tenth of a percent.

Another measure that reflects the divide between the economic elite and all others is the gap in pay between production workers and the CEOs of the companies they work for. In 1970, CEOs’ cash compensation averaged $25 for every $1 earned by nonsupervisory workers. Yet a mere 30 years later the ratio was 90 to 1, and, if the expected value of stock options in CEOs’ compensation is included, the ratio reaches more than 500 to 1.

“Out-of-pocket expenses for health care such as premiums, deductibles and co-payments are an increasing portion of stagnant wages,” Rosenstock said. She noted that one organization estimated that such costs increased by 89 percent from 2003 to 2013. “In 2013, among firms with at least 35 percent of their workforce making $23,000 or less per year, 48 percent of workers for single coverage had a deductible of at least $1,000—a significant portion of their income.”

The commentary points to the health care industry—where there is a large disparity between the salaries for the lowest earners, such as nurses aides, and the top earners, such as surgeons—as one microcosm of the problems caused by inequality and changes in work organization.

“As the costs of medical care have risen in the United States, pressure on the industry has increased to improve efficiency,” said Jessica Allia Williams, the report’s first author, a former UCLA doctoral student in health policy and management who is now a postdoctoral fellow at the Harvard School of Public Health.

As a result, she said, lower-paid workers face the perfect storm of income inequality—being asked to work more with less, while also paying more for insurance premiums and out-of pocket medical expenses.

“Also, across the spectrum, health care workers face relatively high rates of injury owing to physical hazards such as lifting patients or getting stuck by needles,” Williams said, adding that they also are likely to work nonstandard shifts and more overtime and to face hazards such as violence in the workplace that further contribute to poor health.

Rosenstock said the effects of the Affordable Care Act on these trends are still unclear, especially because of the delay in implementing the employer mandate for health insurance. But despite the benefit of having more of the population insured, early evidence suggests that the ACA is causing lower-income workers to have to pay more of the costs of care out of their cash compensation.

“It’s clear that income inequality and working conditions affect the health of the U.S. workforce,” she said. “Although political differences may divide the policy approaches our elected officials may take, addressing income inequality is likely to improve the overall social and health well-being of those currently left behind.”


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Putting a Price-Tag on Inequality

America’s most typical adults would be three-times richer if the United States distributed wealth as equally as France does.

Posted on January 12, 2015
by Sam Pizzigati

How much does inequality cost the average American family? What price do we pay, in actual dollars and cents, for tolerating an economy fixated on pumping our treasure to the top?

That question has no simple answer. Inequality, after all, imposes upon us a wide range of costs that don’t easily reduce to dollars and cents.

How much, for instance, should we value an added year of life? We know — from literally hundreds of research studies over the years — that people live longer, healthier lives in more equal nations.

France and the United States have about the same wealth per adult. But France’s more equal wealth distribution makes a huge difference for average families.

We also know that more equal societies have lower levels of mental illness and fewer teenage pregnancies, fewer homicides and higher levels of trust. How do we place dollar signs on quality-of-life indicators like these? That can get complicated.

On the other hand, dollar signs do come easy when we’re talking about income and wealth. So let’s limit our exploration into the price we pay for tolerating inequality to just these two yardsticks.

The Economic Policy Institute has gone through one exercise along this line. How much income would middle class Americans be making today, EPI researchers asked, if the United States had the same distribution of income today as our nation had back at the end of the 1970s?

The difference between now and then could hardly be starker. Since 1979, households in America’s top 1 percent have more than doubled their share of the nation’s income, from 8 to nearly 20 percent.

What if this increase in inequality had never happened? What if middle class American households were taking in the exact same share of the nation’s income they took in four decades ago?

Economic Policy Institute researchers focused their calculations on 2007, the last year before the Great Recession. In that year, the average middle class income in the United States — the average for the middle 60 percent of American households — amounted to $76,443.

But if middle class households in 2007 lived in an America as equal as the America of 1979, that average income would have been $94,310. In other words, inequality is costing the average American middle class family about $18,000 a year.

That’s comparing, remember, America today with America yesterday. But the global economy, some might argue, has changed fundamentally over the past four decades. We live in a different world. Simple comparisons of then vs. now no longer tell us much.

The United States ranks as the world’s most unequal major developed nation.

For argument’s sake, let’s accept this rather dubious claim — and make a different comparison. Let’s compare the wealth of ordinary Americans today with the wealth of ordinary people in more equal nations.

France makes for a good comparison. France and the United States, the research institute of the Swiss bank Credit Suisse reported last fall, have about the same total wealth per adult.

If you divide the wealth of the United States by our adult population, you end up with $347,845 per adult. If you do the same computing with France’s wealth and population, you end up with $317,292 per adult. The average American would have, in sum, slightly more wealth than the average person in France if both nations divvied up their wealth on a totally equal basis.

But total equality, of course, reigns in neither France nor the United States. The United States ranks as the most unequal major developed nation in the world. France ranks as more equal than nations like the United States and Britain, but less equal than nations like Japan and Sweden.

In France today, “median” adults — those with more wealth than the poorest half of France’s adult population but less wealth than the richest half — have $140,638 in net worth to their name.

In the United States, by contrast, median adult wealth stands at a mere $53,352.

The bottom line? If the United States had as equal a distribution of wealth as France, typical American adults today would have almost triple their current net worth.

So how much does inequality matter to America’s middle class? More than we realize. Much more.

Sam Pizzigati edits Too Much, the Institute for Policy Studies monthly on excess and inequality. His latest book: The Rich Don’t Always Win: The Forgotten Triumph over Plutocracy that Created the American Middle Class, 1900-1970.

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