Poverty and health in the United States

Poverty and health are intertwined in the United States.[1] As of 2019, 10.5% of Americans were considered in poverty, according to the U.S. Government's official poverty measure. People who are beneath and at the poverty line have different health risks than citizens above it, as well as different health outcomes. The impoverished population grapples with a plethora of challenges in physical health, mental health, and access to healthcare. These challenges are often due to the population's geographic location and negative environmental effects. Examining the divergences in health between the impoverished and their non-impoverished counterparts provides insight into the living conditions of those who live in poverty.

U.S. Poverty Trends

A 2023 study published in The Journal of the American Medical Association found that cumulative poverty of 10+ years is the fourth leading risk factor for mortality in the United States, associated with almost 300,000 deaths per year. A single year of poverty was associated with 183,000 deaths in 2019, making it the seventh leading risk factor for mortality that year.[2][3][4][5][6]

Environment and health

The environment of people in poverty impacts their health in many aspects.[7] High poverty areas experience problems associated with poor air quality, water pollution, hazardous and toxic waste, and noise pollution.[7][8] According to Unhealthy Cities: Poverty, Race, and Place in America, poor air quality results in higher rates of children with asthma living in these areas, and nearly 2 million children with asthma live in areas that do not meet national ozone standards.[8] These children are also exposed to greater amounts of allergens that trigger their asthma.[7] Water pollution is also present impoverished cities due which results in unsanitary practices due to poor water supply and sanitation.[9] Impoverished communities are prone to be in proximity to hazardous waste facilities which result in toxic waste dumping, chemical runoff, and water pollution within the area.[8] Because many residents of low-income areas are desperate, they tend to not protest against incoming hazardous facilities.[8] Therefore, these facilities tend to seek out these communities to build in, and this results in more health costs for those in the area.[8] Low-income populations are also more exposed to pesticides, and a significantly higher amount of lead was found in African-American children living in inner-city areas.[7] Neglected Tropical Diseases (NTDs) are also more prevalent in areas of high poverty such as the South and inner-city areas though they often get overlooked by physicians for other diseases.[10]

Climate change also affects the health of those living in low-income communities. Climate change can result in a greater frequency of bad allergy days which results in weakened immune systems and increase asthma cases within the community.[11] From air pollution, respiratory and cardiovascular diseases can worsen due to the greater amounts of chemicals in the atmosphere and hotter temperatures.[11] The warmer temperatures also result in warmer surface water bodies which are better environments for tropical diseases to take root and spread.[11] Climate change also results in higher frequency of storms, hurricanes, and floods which can result in greater damage to infrastructure resulting in more financial stress for people in low-income communities.[11]

Spatial
Main article: Spatial inequality

Health outcomes of those in poverty can also be determined by spatial, or geographic, location which is another aspect of the environment. Opportunities for healthcare, goods and services like food, and community are all based on geography.[12] Childhood/early adulthood settings highly influence behavior, education, and careers.[12] Those who are financially unstable can usually only find homes that are lower-priced in neighborhoods that are not invested in and are not managed well.[7] These homes are often lower quality, and the costs are higher than what can be managed.[7] According to The Link between Neighborhood Poverty and Wealth: Context or Composition?, Residents in a high-poverty neighborhood reports poor health 1.63 times more than a person in a low-poverty neighborhood, even when controlling for factors like education, marital status, and labor force status.[12] For those living in rural areas, health services are not as accessible, and impoverished people go to doctors fewer times than their counterparts.[1] The effect of spatial location is seen in both physical and mental health.

Poverty and physical health

Poverty can affect health outcomes throughout a person's entire life. The affect may not always be expressed while an individual is impoverished. Mothers who are in poverty during their pregnancies may experience more health risks during their delivery, and their newborn may experience more health risks and markedly more behavioral problems during their development.[13] Furthermore, children in poverty have worse health outcomes during adulthood. This effect is especially pronounced for specific ailments, such as heart disease and diabetes. The impact persists even if a youth escapes poverty by adulthood, suggesting that the stress of poverty encountered during childhood or adolescence has a lasting effect.[14] Previous research has identified the labor environments of the impoverished as more likely to contain risk factors for illness and disability relative to their non-impoverished counterparts.[15] The implication is that the unique stresses of life within an impoverished community contribute to poorer health outcomes, even if the resident does not engage in any specific behavior detrimental to their health.[16] Early into the COVID-19 pandemic in North America, being impoverished was associated with an increased likelihood of contracting COVID-19, as well as dying from it.[17]

Poor housing results in many health problems. Accidents, respiratory disease, and lead poisoning can be caused by poorly built housing.[7] There can also be a lack of safe drinking water, pests, and dampness in the house, and gonorrhea is associated with deteriorating houses.[7] Mothers who live in poverty areas have lower rates of prenatal care and higher rates of infant mortality and low birth weight.[18] Tuberculosis rates are also higher in high-poverty areas.[18] Obesity is associated with poverty due to lack of infrastructure that supports a healthy lifestyle.[19] Often, poverty-areas do not have places to walk or get healthy food nearby, and they are bombarded with unhealthy promotions like cigarettes, alcohol, and fast food.[19] High-poverty areas also had higher death rates than low-poverty areas.[18][20]

Cost of housing is a huge detriment to physical health. Housing is what the poor pay the most for on a regular basis, and this results in lack of funds for other basic needs like food and health.[7][19][21] In a National Health Interview Survey, it was found that around 10% of American families did not receive needed medical care because of cost.[22] Food insecurity also increases due to being unable to buy food due to cost.[23]

According to a 2023 study published in JAMA, cumulative poverty of a decade or more is the fourth leading risk factor for death in the United States annually, being associated with 295,000 deaths. A single year of poverty was associated with 183,000 deaths in 2019, making it the seventh leading risk factor.[4] Up until the age of 40, poor people's survival rates were essentially comparable to those of more affluent people, according to UCR researchers, but after that point, they died at a rate that was noticeably higher.[5][6]

Poverty and mental health
Main article: Poverty and mental health

Poverty also has a complex relationship with mental health. Being in poverty may itself provoke a condition of elevated emotional stress, known as "poverty distress".[24]  Poverty is also a precursor or risk factor for mental illness, particularly mood disorders, such as depression and anxiety. Schizophrenia is also strongly associated with poverty, occurring most frequently in the poorest classes of people all over the world, especially in more unequal countries.[25]  In a sort of reciprocating relationship, having mental illness is a major risk factor for being in poverty.  Having a mental illness may inhibit a person's ability to work or deter employees from hiring them.

A hypothesis known as "drift hypothesis", posits that for people with psychiatric disorders (primarily schizophrenia), they tend to fall further down the socioeconomic ladder as their condition reduces their functionality.  This hypothesis is an effort to establish that people with profoundly limiting psychiatric symptoms are more likely to descend economically, not that the financially challenged are more likely to present severe psychiatric disorders. People experiencing less severe symptoms are less likely to be affected by "drift".[24]  

Receiving treatment has shown positive effects for those struggling with mental illness and poverty.

With those in poverty having greater likelihood of suffering from mental illness, the benefit of access to clinical psychotherapy treatments has been explored. Despite numerous barriers for access to care for low-income individuals, there is evidence that those who do receive care respond with significant improvements. This research supports policy measures for improved outreach and access-to-care measures designed to benefit those with low-incomes and mental health disorders.[26]

Mental health is affected by location as well. Noisy housing impacts reading in children and promotes psychological stress.[7] Many poor families move more often and are residentially instable. This results in children experiencing instability with relationships with peers.[7] They also experience more stressful life events which places strain on their mental state as the events cumulate.[7][11] As both parents and children try to cope, they may cut themselves off from social interactions and healthy development.[7]

Race and health
Main article: Race and health in the United States

Poverty and race both impact the health outcome of a person.[18] Of the residents in poverty-areas, well over half are people of color.[18] When compared to White Americans, all other races have lower outcomes of infant mortality, low birth weight, prenatal care, and deaths in cities.[18] People of Color have an 80% higher mortality rate than White people, and this includes deaths from cancer, accidents/homicides, and disease.[1] Those in severe poverty are more likely to be Black Americans and Latinx.[19] More than one-fourth of the Native American and Alaska Native population lives in poverty.[27] When adjusted for age, the death rate of Native Americans and Alaska Natives is 40% higher than the general population, and 39% of the children are obese or overweight.[27] Mental health is the number one problem in the Native American and Alaska Native population.[27] For Black Americans, racial segregation in neighborhoods are barriers for equitable health opportunities.[7] Most current neighborhoods that are predominantly Black have been institutionally disinvested and have fewer public services and more housing insecurity.[7] With these barriers, many Black Americans do not have the wealth of a family home passed down through generations.[7] Latinx and Asians may also have trouble with home ownership due to cultural and linguistic isolation.[7]

Homelessness and health
This section is an excerpt from Homelessness in the United States § Health.[edit]

Homelessness is a public welfare and health epidemic within the United States. Any period of homelessness is associated with adverse health consequences.[28] These adverse health consequences are associated with poor living conditions and a lack of access to treatment facilities. Due to living in extreme poverty it is unlikely for an individual or a family to have a healthcare plan. These healthcare plans are important in obtaining treatment for illnesses or injury from treatment facilities. Without it, individuals and families are left to deal with their ailments themselves or endure further financial burden by receiving treatments without a health insurance plan. Respiratory infections and outbreaks of tuberculosis and other aerosol transmitted infections have been reported. Homeless intravenous drug users are at an increased risk of contracting HIV, and hepatitis B and C infections.

[29] The close living spaces of areas such as Skid Row in California provide an environment in which infectious diseases can spread easily. These areas with a high concentration of homeless individuals are dirty environments with little resources for personal hygiene. It was estimated in a report to congress that 35% of homeless were in unsheltered locations not suitable for human habitation.[30]

There is a bidirectional relationship between homelessness and poor health.[31] Homelessness exacts a heavy toll on individuals and the longer individuals experience homelessness, the more likely they are to experience poor health and be at higher risk for premature death.[32] Health conditions, such as substance use and mental illness, can increase people's susceptibility to homelessness. Conversely, homelessness can further cause health issues as they come with constant exposure to environmental threat such as hazards of violence and communicable diseases. Homeless people have disproportionately high rates of poly substance use, mental illness, physical health problems and legal issues/barriers in attaining employment.[33]

Large number of homeless people work but few homeless people are able to generate significant earnings from employment alone.[34] Physical health problems also limit work or daily activities which are barriers to employment. Substance use is positively associated with lower work level but is negatively related to higher work level.[35] Those with physical health problems are substantially more likely than those with mental health problems to be in the more generous disability programs. Substance use disorders are also a barrier to participation in disability programs. Rates of participation in government programs are low, and people with major mental disorders have low participation rate in disability programs.[36]

Around the United States, homeless deaths surged 77% from 2016 to 2020. An analysis from The Guardian in February 2022 found that some 18,000 homeless people died on the streets and in encampments and shelters over a five year period, with 5,000 of these deaths occurring in 2020. The non-profit National Health Care for the Homeless Council places homeless deaths at between 17,000 and 40,000 annually, as many are never counted given the federal government does not track homeless deaths nationally. The top direct causes of death among the homeless population include "drug overdoses, violence, traffic deaths and premature lethality of treatable conditions like heart disease." Regarding drug deaths, methamphetamine is a significant killer, as people who are homeless use the stimulant drug to stay awake and alert in order to protect themselves from violence. The report also notes that, outside of direct medical causes of death, a major factor contributing to both the epidemic of homelessness and surge in deaths among the homeless population is the lack of affordable housing throughout much of the country.[37]

Homelessness among the elderly has been increasing.[38] The Los Angeles County Department of Public Health found that homeless persons die at greater rates than the general public from specific causes.[39] They are more likely to die by: 35 times from alcohol or drug overdoses, 16 times from auto accidents, 14 times from murder, 8 times from suicide, and 4 times from heart disease.[39] According to data from HUD in September 2023, the elderly are now the fastest growing demographic of the homeless population.[40]

Judge Milan Smith Jr., an American jurist claimed that homelessness is "presently the defining public health and safety crisis in the western United States."[41] According to the Lahsa data, on average six unhoused people are dying each day. the causes reported of death are Overdoses, heart disease, traffic accidents, homicides, hypothermia, and heat exhaustion.Va Lecia Adams Kellum, Lahsa's CEO, believes "The primary causes of homelessness are economic."[42]

Health care policy
Main article: Health care in the United States

Between 1987 and 2005, the number of people without health insurance in the United States rose from just over 30 million, to 46.6 million.[43] Insurance tends to increase the price of services,[9] and at that time, 8.5% of people belonging to households that made over $75,000 annually were uninsured. For families earning $25,000 or less, that percentage rose to 24.4% uninsured.[43] This figure exhibits how lack of access to care via health insurance disproportionately affects those in poverty.

Graph from U.S. Census Bureau on rates of uninsuredGraph showing

Despite the cost of healthcare being an obstacle for those with relatively low incomes, research suggests that insurance coverage will not dramatically change outcomes related to physical health.  Access to Medicaid for low-income adults aided in diagnosis of metabolic disease, saw a reduction in diagnosis of mental health disorders, and reduced incurrence of "catastrophic medical costs" by patients dramatically. While these positive effects were observed, outcomes for heart disease, diabetes, and other physical health characteristics were not meaningfully improved. It has been posited that one year, the duration of the study, is an insufficient length to fully observe the divergent health outcomes that would be characteristic of an experiment with a lengthier time-table.[44] Also, minorities have an excess amount of deaths due to diseases like cancer and cardiovascular disease compared to whites.[1]

The medical-industrial complex also contributes to the difficulties of patients paying for medications and healthcare costs.[45]

Actions taken by the government

The United States government has passed acts to make healthcare more accessible.[46] Though it does not have universal health coverage, the country has two forms of public insurance, Medicare and Medicaid. Medicare is insurance for those who are over 65 or have long-term disabilities or end-stage renal disease.[46] Medicaid allows for federal funding to match health care services and allow low-income families, low-income pregnant women, low-income children up to 18 years old, the blind, and those with disabilities to have these services.[46] Medicaid is administered by states, so states have the right to set the criteria for eligibility. According to The Commonwealth Fund website, Medicaid now covers 17.9% of Americans. The Children's Health Insurance Program (CHIP) provides insurance to children in low-income families and covers 9.6 million children, according to The Commonwealth Fund.[46] The Affordable Care Act was passed in 2010, and it expanded Medicaid eligibility and provided funding for federally qualified health centers. These centers take patients regardless of ability to pay and provides free vaccines to uninsured and underinsured children.[46] Community mental health services are also funded by the federal government through grants provided to states by the Substance Abuse and Mental Health Services Administration.[46]

Recommendations to further improve

One recommendation to address the inequity of healthcare for the poor is to take community-based action.[1][47] One example of this is county health councils in Tennessee. These are volunteer groups from the community who assess health inequities within their county and decide what policies to implement.[47] Another idea is to implement community-oriented primary care where physicians consider the environment and culture of the patient to further their health.[1] To improve housing, weatherization programs are recommended to refurbish poor housing to be more health friendly.[21]

Policy wise, it is recommended to continue investing in the health of the poor by creating an amendment or law and increasing affordable housing.[11][48] The amendment would ensure that adequate housing is a right to be enjoyed by everyone, and if that could not happen, then a law could be passed for a better housing policy.[11] Affordable housing can be increased by increasing subsidies through housing vouchers for households or reduced interest loans for developers.

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