David Ansell has worked in Chicago’s health care system for over four decades, as a primary care physician and epidemiologist. In under 200 well-written pages he shows just how unhealthy, even deadly, it is to be poor, black or hispanic in American society. With experience ranging from a public hospital that takes all comers (most without insurance), to a highly sophisticated academic medical center, he is in a good position to know. And he’s given a good deal of thought to how to fix American health care.
People who are poor, particularly those who live in areas of concentrated poverty (like inner cities or rural Appalachia), and most especially African Americans in such environments, have measurably worse health, higher death rates and lower life expectancy than the rest of us.
The basic point is that people who are poor, particularly those who live in areas of concentrated poverty (like inner cities or rural Appalachia), and most especially African Americans in such environments, have measurably worse health, higher death rates and lower life expectancy than the rest of us. That this seems obvious to us is itself a commentary on American society. Ansell spends much of the book showing that common explanations for this pattern are not adequate.
We can’t explain it by self-destructive behavior or poor life choices, because even people who try to be responsible and do the right thing their lives still suffer systematic disadvantages just from living in poverty. For example, women from poor sections of Chicago who sought treatment for breast lumps were measurably less likely to get the best treatment than women in non-poor areas.
We can’t explain it by biology or genetics. It has been shown that African Americans are not systematically, biologically predisposed to ill health. They get it from their living conditions.
We can’t explain it by culture: African Americans, or Appalachian Americans are, after all, culturally American. If they have a chance to get out of the areas of concentrated poverty, they become measurably healthier, even though their culture hasn’t changed.
We can’t explain it by bad luck. The deck is stacked, both in society in general, and in the health care system in particular, against the poor and especially against African Americans.
Ansell would not have us forget about slavery and legal segregation, but he emphasizes how even up to the present, deliberate public policies systematically disadvantage the poor and the black. Decades of government policy in the twentieth century denied blacks access to mortgages and prevented them from moving out of areas of concentrated poverty. Public schools in such areas were under-financed and inferior to those in the suburbs. Expressways facilitated white flight from inner cities to the suburbs, while public transportation was not designed to help inner city residents get out. Government policy at all levels promoted moving urban factories to suburbs, to other regions of the country, or to other countries, but nothing was done to assist inner city residents in following those jobs.
The health care system itself has a strong class and race bias. Everything depends on having insurance, and if you are poor, you can’t afford it. If you qualify, there is Medicaid; if you’re old enough, there is Medicare. Otherwise, you are out of luck. It is a system designed to make profits for the big insurance companies. This is why hospitals in poor areas are inferior to those in affluent areas.
Angel argues that the only way to equity in health care is by conceiving it as a human right, and by having a single payer, government-run financial system. He admits that, against the vested interests of the insurance companies, that’s not going to happen soon. He thinks Obamacare is deeply flawed but needs to be defended and improved. And he’s a strong advocate (following Dr. Paul Farmer) of local communities and health care providers doing what they can to improve the fair distribution of good quality care for all.
But ultimately, inequality kills.