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DYING YOUNG: WHY YOUR SOCIAL AND ECONOMIC STATUS MAY BE A DEATH SENTENCE 

IN AMERICA 

HEARING 

BEFORE THE

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING 

OF THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

ON

EXAMINING HEALTH RELATING TO SOCIAL AND ECONOMIC STATUS 

NOVEMBER 20, 2013 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

TOM HARKIN, Iowa, Chairman 

BARBARA A. MIKULSKI, Maryland 

PATTY MURRAY, Washington 

BERNARD SANDERS (I), Vermont 

ROBERT P. CASEY, JR., Pennsylvania 

KAY R. HAGAN, North Carolina 

AL FRANKEN, Minnesota 

MICHAEL F. BENNET, Colorado 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

LAMAR ALEXANDER, Tennessee 

MICHAEL B. ENZI, Wyoming 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

LISA MURKOWSKI, Alaska 

MARK KIRK, Illinois 

TIM SCOTT, South Carolina 

PAMELA SMITH, Staff Director 

LAUREN MCFERRAN, Deputy Staff Director and Chief Counsel 

DAVID P. CLEARY, Republican Staff Director 

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

BERNARD SANDERS, Vermont, Chairman 

BARBARA A. MIKULSKI, Maryland 

KAY R. HAGAN, North Carolina 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

TOM HARKIN, Iowa (ex officio) 

RICHARD BURR, North Carolina 

PAT ROBERTS, Kansas 

LISA MURKOWSKI, Alaska 

MICHAEL B. ENZI, Wyoming 

MARK KIRK, Illinois 

LAMAR ALEXANDER, Tennessee (ex officio) 

SOPHIE KASIMOW, Staff Director 

RILEY SWINEHART, Republican Staff Director 

(II) 

C O N T E N T S 

STATEMENTS 

WEDNESDAY, NOVEMBER 20, 2013 

Page 

COMMITTEE MEMBERS

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health and 

Aging, opening statement .................................................................................... 1 

Warren, Hon. Elizabeth, a U.S. Senator from the State of Massachusetts ........ 2 

Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin .................. 36 

WITNESSES

Woolf, Steven, M.D., MPH, Director of The Center on Society and Health, 

and Professor of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA ............................................................... 3 

Prepared statement .......................................................................................... 5 

Berkman, Lisa, Ph.D., Director of the Harvard Center for Population and 

Development Studies and Thomas D. Cabot Professor of Public Policy and 

Epidemiology, Harvard University, Cambridge, MA ........................................ 19 

Prepared statement .......................................................................................... 21 

Eberstadt, Nicholas, Ph.D., MPA, M.Sc., Henry Wendt Chair in Political 

Economy, American Enterprise Institute, Washington, DC ............................. 24 

Prepared statement .......................................................................................... 25 

Kindig, David A., M.D., Ph.D., Emeritus Professor of Population Health 

Sciences, University of Wisconsin School of Medicine and Public Health, 

Madison, WI ......................................................................................................... 37 

Prepared statement .......................................................................................... 39 

Shrader, Sabrina, Athens, WV ............................................................................... 42 

Prepared statement .......................................................................................... 44 

Reisch, Michael, Ph.D., MSW, Daniel Thursz Distinguished Professor of Social 

Justice, University of Maryland School of Social Work, Baltimore, MD ......... 45 

Prepared statement .......................................................................................... 47 

(III) 

(1) 

DYING YOUNG: WHY YOUR SOCIAL AND ECONOMIC STATUS MAY BE A DEATH SENTENCE IN AMERICA 

WEDNESDAY, NOVEMBER 20, 2013 

U.S. SENATE, 

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING, 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 10 a.m. in room 

SD–430, Dirksen Senate Office Building, Hon. Bernard Sanders, 

chairman of the subcommittee, presiding. 

Present: Senators Sanders, Baldwin, Murphy, and Warren. 

OPENING STATEMENT OF SENATOR SANDERS

Senator SANDERS. Let me thank our wonderful panelists for 

being here to discuss an issue of huge consequence for our country. 

I think what will be happening during the morning is Senators will 

be drifting in and out. It is a particularly busy time. But the issue 

that we are going to be discussing is something that needs to be 

worked on a whole lot. 

The first point that has to be made is that in this great country, 

we see huge disparities in terms of how long people live; life expectancy. I think people would be shocked if they knew that in this 

country—just between neighborhoods in a given city or areas of our 

country—you will find in one place people living rather long and 

healthy lives, and in other parts of the country, people living much 

shorter lives often plagued by illness. 

One point that I want to make is that when we talk about poverty, I think a lot of people say, ‘‘Well, somebody is poor who maybe 

lives in inadequate housing, and that is just too bad,’’ or may not 

have a good automobile, or may not even be able to go to college, 

or afford to go to college; all of that is true. But poverty and the 

stress of poverty is much, much more than that, and in many ways 

in our country, the stress of poverty is a death sentence which results in significantly shorter life expectancy. 

One of our witnesses today, Dr. Kindig, published a paper earlier 

this year in ‘‘Health Affairs’’ showing that female mortality rose— 

rose—in the United States in 43 percent of U.S. counties between 

1992 and 2006. That women in those counties are actually dying 

at a younger age. 

The goal of everything that we do in this sense, is that we strive 

to figure out ways in which people can live longer and happier 

lives. That is really what it is about. People may disagree about 

2 

how to get there, but that is the goal. But when we find that female mortality rose in 43 percent of U.S. counties between 1992 

and 2006, that is a profound reality that has got to be dealt with. 

Right here in the Nation’s Capital, in Washington, DC, life expectancy varies from 77 years in the District to 84 years in Montgomery County just a few metro stops away; a 7 year difference in 

life expectancy for women. The county with the highest life expectancy is Marin County in northern California where the average life 

expectancy is 85 years, which stacks up pretty well with the rest 

of the world. 

We, as a Nation, are behind many other countries in terms of life 

expectancy and that, in itself, is worthy of serious discussion. In 

Marin County, CA, women live to be 85 years of age, which is good. 

The lowest in the Nation is Perry County, KY with an average life 

expectancy for women of 73 years; 12 years less in the United 

States of America. 

For men, the highest life expectancy occurs in nearby Fairfax 

County outside of Washington, DC where the average is 82 years 

for men; that is pretty good. This compares to a life expectancy of 

64 years for men in McDowell County, WV where one of our guests 

is from. That is an 18-year gap within the United States of America. Men born in Marin County will live 18 years longer than men 

in McDowell County, WV. 

One of our witnesses today, Sabrina Shrader, grew up in 

McDowell County, WV, where men have the same average life expectancy as men in Botswana or Namibia. Women in McDowell 

County have shorter lives than women in El Salvador or Mongolia, 

and the gaps in life expectancy within our country are widening, 

and today’s hearing will call attention to this troubling fact. 

We know that there are disparities in life expectancy based on 

gender, race, and socioeconomic status. It is becoming increasingly 

clear that education plays a critical role of determining how long 

someone will live. Those without a high school education in the 

United States, of all races, live shorter lives and experience poorer 

health than those with higher levels of education. In fact, a white 

woman without a high school education saw her life expectancy 

drop 5 years from 1990 to 2008. 

The issue that we want to explore today is why that is so. Why 

we are seeing, in some cases, people in our country living shorter 

lives than their parents did? We want to look at why this disparity 

exists. We want to understand almost the physiology of what poverty is about. 

What does stress mean? What does it mean if you wake up in 

the morning, and you are not quite sure if you and your kids are 

going to have enough food? If you do not have a job, what does it 

mean to you, personally, and how does that result overall in shortening your life? 

This is a very important and profound discussion, and we are so 

pleased to have our knowledgeable panelists with us. I see Senator 

Warren here. 

Senator Warren, do you want to make some opening remarks? 

STATEMENT OF SENATOR WARREN

Senator WARREN. Thank you very much, Chairman Sanders. 

3 

Thank you very much for calling this hearing and thank you all 

for being with us today. I will be brief because I want to get to your 

questions so that we can ask more, but I do want to say after reading our notes, this is something you and I have talked about a lot. 

Our witnesses have highlighted how the health of our citizens is 

tied to our economy. We know that income is one of the best predictors of life expectancy, as you have pointed out, but I would add, 

that it is also one of the best indicators of other health problems— 

asthma, diabetes, mental health disorders, the list is just starting—in which we know that income has a profound influence on 

the likelihood of having those problems and the severity of those 

problems. 

So when we talk about reducing costs in the healthcare system 

and improving the health of Americans generally, I think we have 

to take a step back and take a very hard look at what is happening 

to the economy in the United States; how these things fit together. 

How greater income inequality is having a profound effect, not only 

on the economic life of Americans, but also on their health and the 

health of their children. 

With that, I want to go straight to hearing from our witnesses 

if we can. 

Thank you, Mr. Chairman. 

Senator SANDERS. We certainly can, and thanks very much. 

Our first witness is Dr. Steven Woolf. Dr. Woolf is a professor of 

family medicine and population health, and director of the Center 

on Society and Health at the Virginia Commonwealth University; 

an expert on primary care and public health. He received his training at Emory University, Johns Hopkins University, and Virginia 

Commonwealth University, and has worked for 25 years in academic and public policy settings. 

Dr. Woolf, thanks so much for being with us. 

STATEMENT OF STEVEN WOOLF, M.D., MPH, DIRECTOR OF 

THE CENTER ON SOCIETY AND HEALTH, AND PROFESSOR 

OF FAMILY MEDICINE AND POPULATION HEALTH, VIRGINIA 

COMMONWEALTH UNIVERSITY, RICHMOND, VA 

Dr. WOOLF. Thank you, Senator Sanders. Thank you, Senator 

Warren. It is a pleasure to be here to testify on this important 

issue. 

Our Center, the Center on Society and Health study how factors 

outside of healthcare shape health outcomes. One such factor is income. The lower people’s income, the earlier they die and the sicker 

they live. The poor have higher rates of a long list of diseases such 

as diabetes, heart disease, depression, and disability, as Senator 

Warren mentioned. 

But it is not just the poor. The health of working-class and middle-class, and even upper-class Americans also rises and falls with 

our socioeconomic status. Take this for example, 68 percent of 

American adults have an income that is more than twice the poverty level. Suppose we boosted that number just slightly from 68 

percent to 70 percent and looked at the impact on one disease, diabetes. That higher income would mean about 400,000 fewer cases 

of diabetes, saving $2.5 billion dollars per year to treat that one 

disease. 

4 

If economic conditions matter so greatly to health and healthcare 

costs, the reverse is also true. Harder times for the middle class 

and the poor mean that Americans and their children will get sicker and die earlier. Already, the health of Americans is inferior to 

that of people in other high-income countries. 

I recently chaired an expert panel convened by the National Research Council and the Institute of Medicine. We compared the 

United States with 16 other high-income countries and found that 

Americans die earlier and have higher rates of disease and injury. 

The U.S. health disadvantage exists for men and women, for 

young and old, and as this table shows on the easel, across multiple areas of health from infant mortality to traffic fatalities, from 

teen pregnancies to diseases of the heart and lungs, diabetes, and 

disability. American children are less likely to reach age 5 than 

children in other rich Nations. Our babies are less likely to reach 

their first birthday. Our rate for premature babies is similar to 

sub-Saharan Africa. 

The U.S. health disadvantage is not restricted to the poor and 

minorities; it is seen among all social classes, the rich and poor, 

more-educated and less-educated Americans. But the problem is 

clearly worse for those with less-income, and the socioeconomic picture for the average American family is not good. 

Although in aggregate our Nation is wealthy, we have high rates 

of income inequality, and thus, high poverty rates. For three decades, we have had the highest child poverty rate in the industrialized world. These conditions affect health and when we die. 

Consider my State, Virginia, home to the two most affluent counties in the country, but also home to rural areas with deep poverty. 

Our Center found that 25 percent of all deaths in Virginia would 

be averted if everyone had the death rate of Virginia’s five most affluent areas. Let me repeat, that is one out four deaths. 

This reflects not just the difference in the loss of the people who 

live in those counties, but the economic and social capital of the 

communities themselves. These differences produce big gaps in life 

expectancy across a matter of miles. 

We produced a metro map of Washington, DC showing that lives 

are 7 years shorter in DC than in the Maryland suburbs at the end 

of the Red Line, as Senator Sanders mentioned. 

In New Orleans, if you can show the next map, we found that 

a baby born in ZIP Code 70112 can expect to live 25 fewer years 

than a baby born in ZIP Code 70124. 

Neighborhoods in Boston and Baltimore have a lower life expectancy than Ethiopia and Sudan. Azerbaijan has a higher life expectancy than areas of Chicago. 

What is the take away for Congress? First of all, it is that economic policy is not just economic policy, it is health policy. Pocketbook issues affect disease rates and how long Americans live. Strategies to strengthen the middle class and relieve poverty can prevent costly diseases like diabetes, which leads to the second major 

takeaway: relieving economic hardship for Americans is a smart 

way for Congress to control medical spending. 

Spiraling healthcare costs are a big concern here in Congress and 

in corporate America. We are all searching for ways to bend the 

cost curve. What better way than reducing the flow of disease into 

5 

the system? Earlier I mentioned that 25 percent of all deaths in 

Virginia could be averted. No form of healthcare reform and no 

treatments by doctors and hospitals can rival that kind of effect. 

The third takeaway is that health is affected not only by what 

is in your bank account, but also by policies that put people on the 

road to economic success such as helping our young people get a 

good education. Investments in early childhood are key to our Nation’s future and to their life expectancy. Legislation that puts 

American families on a stronger footing, and strengthens the physical and social environment in which they live, like those neighborhoods in New Orleans and Baltimore, can be good for the economy 

and public health, thereby curbing healthcare costs. 

The opposite is true: cutting these programs in an attempt to 

save money could save nothing if it makes people sicker and thereby drives up medical spending. A sicker population means a sicker 

workforce, making American businesses less competitive and our 

military less fit for duty. Our economy, and national security, cannot afford this and nor can our people. 

Thank you. 

[The prepared statement of Dr. Woolf follows:] 

PREPARED STATEMENT OF STEVEN WOOLF, M.D., MPH 

Thank you, Senators Sanders and Burr. I’m Steven Woolf and I appreciate the 

opportunity to testify this morning. I’m a family physician and I direct Virginia 

Commonwealth University’s Center on Society and Health. Our center studies how 

factors outside of health care shape health outcomes. One such factor is income. 

This committee needs no reminders about the importance of income to American 

families. What’s perhaps less apparent is how greatly economic conditions affect the 

health of adults and children—and by extension the costs of health care. 

The lower people’s income, the earlier they die and the sicker they live. The poor 

have higher rates of a long list of diseases such as diabetes, heart disease, depression, and disability. Children raised in poverty grow up with more illnesses. 

But it’s not just the poor. The health of working class and middle class and even 

upper class Americans also rises and falls with their socioeconomic status. Let’s look 

at an example: 68 percent of American adults have an income that is more than 

twice the poverty level. Suppose we boosted that number just slightly, from 68 percent to 70 percent and looked at the impact on one disease—diabetes. That higher 

income would mean about 400 million fewer cases of diabetes, saving $2 billion per 

year to treat that disease. 

If economic conditions matter so greatly to health and health care costs, the reverse is also true. Subjecting the middle class and the poor to harder times means 

that Americans, and their children, will get sicker and die earlier. 

Already, the health of Americans is inferior to that of people in other high-income 

countries. I recently chaired an expert panel convened by the National Research 

Council and the Institute of Medicine. We compared the United States with 16 other 

high-income countries and found that Americans die earlier and we have higher 

rates of disease and injury. This U.S. health disadvantage exists for men and 

women, for young and old, and across multiple areas of health, from infant mortality to traffic fatalities, from teen pregnancies to diseases of the heart and lung, 

diabetes, and disability. 

American children are less likely to reach age 5 than children in other rich nations. Our babies are less likely to reach their first birthday. Our rate for premature 

babies is similar to sub-Saharan Africa and our teenagers are sicker than teens elsewhere. 

The U.S. health disadvantage is not restricted to the poor and minorities. It’s seen 

among all social classes, the rich and poor, more-educated and less-educated, whites 

and people of color. 

But the problem is clearly worse for those with less income, and the socioeconomic 

picture for the average American family is not good. Although in aggregate our Nation is wealthy, we have notoriously high rates of income inequality and thus for 

three decades our relative poverty rates, especially child poverty rates, have been 

the highest in the industrialized world. America is the land of opportunity but studVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
6 

*Steven H. Woolf (swoolf@vcu.edu) is the director of the Center on Human Needs and a professor in the Department of Family Medicine at Virginia Commonwealth University, in Richmond. 

† Paula Braveman is the director of the Center on Social Disparities in Health at the University of California, San Francisco (UCSF), and a professor of family and community medicine 

at UCSF. 

ies show that the ability of a poor child to climb the economic ladder and escape 

poverty is lower here than elsewhere. 

These conditions affect health—and when we die. Consider my State, Virginia— 

home to the two most affluent counties in the country but also home to rural areas 

with deep poverty. Our center found that 25 percent of all deaths in Virginia would 

be averted if everyone had the death rate of Virginia’s five most affluent areas. Let 

me repeat—one out of four deaths. 

What this reflects is not just a difference in the wealth of the people living in 

those counties but the economic vitality, infrastructure, and social capital of the 

communities themselves. Together, these factors produce vast differences in life expectancy across small distances. We produced this metro map of Washington, DC, 

showing that lives are 7 years shorter in DC than in the Maryland suburbs at the 

end of the Red Line. In New Orleans, we found that a baby born in zip code 70112 

can expect to live 25 fewer years than a baby born in zip code 70124. Neighborhoods 

in Boston and Baltimore have a lower life expectancy than Ethiopia and Sudan. 

Azerbaijan has a higher life expectancy than areas of Chicago. 

What’s the takeaway for Congress? First of all, economic policy is not just economic policy—it’s health policy. Pocketbook issues affect disease rates and how long 

Americans will live. Strategies to strengthen the middle class and relieve poverty 

can prevent costly diseases like diabetes, which leads to the second major takeaway: 

relieving economic hardship for Americans is a smart way for Congress to control 

medical spending. Spiraling health care costs are a big concern here in Congress 

and in corporate America. We are all searching for ways to bend the cost curve. 

What better way than reducing the flow of disease into the system? Earlier I mentioned that 25 percent of all deaths in Virginia could be averted. No form of health 

care reform, and no treatments by doctors and hospitals, can rival that kind of effect. 

The third takeaway is that health is affected not only by what’s in your bank account but also, perhaps more importantly, by policies that put people on the road 

to economic success, such as helping our young people get a good education. Deaths 

from diabetes are three times higher for Americans without a high school diploma. 

Investments in early childhood are keys to our Nation’s future, and to their life expectancy. The laws you pass that strengthen the physical and social environment 

in which Americans live, like those neighborhoods in New Orleans and Baltimore, 

can both grow the economy and also save lives and curb health care costs. 

And now to my last point: Many of these programs are in jeopardy because of fiscal pressures to cut spending. Education reform, job training, urban renewal, and 

safety net programs may not seem like health expenditures but they affect health 

and medical spending nonetheless. There are forms of discretionary spending that 

are keys to curbing entitlement spending on health care. 

Slashing these programs could be counterproductive. I urge Congress to consider 

how proposed cuts outside the health sector will affect disease rates. Cutting a program to save money may save nothing if it makes people sicker and thereby drives 

up the costs of health care. And a sicker population means a sicker workforce, making American businesses less competitive and our military less fit for duty. Our 

economy and national security can’t afford this, and nor can our people. 

Attachment By Steven H. Woolf * and Paula Braveman† 

WHERE HEALTH DISPARITIES BEGIN: THE ROLE OF SOCIAL AND ECONOMIC

DETERMINANTS—AND WHY CURRENT POLICIES MAY MAKE MATTERS WORSE

ABSTRACT: Health disparities by racial or ethnic group or by income or education 

are only partly explained by disparities in medical care. Inadequate education and 

living conditions—ranging from low income to the unhealthy characteristics of 

neighborhood and communities—can harm health through complex pathways. 

Meaningful progress in narrowing health disparities is unlikely without addressing 

these root causes. Policies on education, child care, jobs, community and economic 

revitalization, housing, transportation, and land use bear on these root causes and 

have implications for health and medical spending. A shortsighted political focus on 

7 

reducing spending in these areas could actually increase medical costs by magnifying disease burden and widening health disparities. 

In 2003 the landmark Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care drew needed attention to disparities in the health care of racial and ethnic minorities.1 The response from the 

health care and policy communities included new initiatives to standardize treatments for racial and ethnic minorities, heighten providers’ cultural competency, and 

increase minority representation among health care professionals. 

Although some disparities in health care have narrowed, disparities in the health 

of minority and disadvantaged populations have persisted. Since the 1960s, the mortality rate for blacks has been 50 percent higher than that for whites, and the infant 

mortality rate for blacks has been twice as high as that for whites.2 3 Health disparities exist even in health care systems that offer patients similar access to care, such 

as the Department of Veterans Affairs,4 which suggests that disparities originate 

outside the formal health care setting. 

SOCIAL DETERMINANTS OF HEALTH

Understanding health disparities requires a fresh look at the determinants of 

health itself, the most obvious being intrinsic biological attributes such as age, sex, 

and genes. Some other risk factors that affect health are referred to as ‘‘downstream’’ determinants because they are often shaped by ‘‘upstream’’ societal conditions. Downstream determinants include medical care; environmental factors, such 

as air pollution; and health behaviors, such as smoking, seeking or forgoing medical 

care, and not adhering to treatment guidelines.5

Exposure to these determinants is influenced by ‘‘upstream’’ social determinants 

of health—personal resources such as education and income and the social environments in which people live, work, study, and engage in recreational activities. These 

contextual conditions influence people’s exposure to environmental risks and their 

personal health behaviors, vulnerability to illness, access to care, and ability to 

manage conditions at home—for example, the ability of patients with diabetes to 

adopt necessary lifestyle changes to control their blood sugar.6 7 8 9 10 11 12 Social determinants are often the root causes of illnesses and are key to understanding 

health disparities. 

Income. Income—with education, one of the most familiar social determinants— 

has a striking association with health (Exhibit 1).11 Paula Braveman and Susan 

Egerter have shown that U.S. adults living in poverty are more than five times as 

likely to report being in fair or poor health as adults with incomes at least four 

times the Federal poverty level.8 The income-health relationship is not restricted to 

the poor: Studies of Americans at all income levels reveal inferior health outcomes 

when compared to Americans at higher income levels.10

8 

That income is important to health might not be surprising to some, but the magnitude of the relationship is not always appreciated. For example, Nancy Krieger 

and colleagues estimated that 14 percent of premature deaths among whites and 30 

percent of premature deaths among blacks between 1960 and 2002 would not have 

occurred if everyone had experienced the mortality rates of whites in the highest 

income quintile.13 Steven Woolf and coauthors calculated that 25 percent of all 

deaths in Virginia between 1996 and 2002 would have been averted if the mortality 

rates of the five most affluent counties and cities had applied statewide.14 Peter 

Muennig and colleagues estimated that living on incomes of less than 200 percent 

of the Federal poverty level claimed more than 400 million quality-adjusted lifeyears between 1997 and 2002, meaning that poverty had a larger effect than tobacco 

use and obesity.15

Such estimates rely on certain assumptions and do not prove causality. However, 

the consistency of the evidence supports the conclusion that income, or the conditions associated with income, are important determinants of health. 

Education. Like income, education has a large influence on health (Exhibit 2). 

An extensive literature documents large health disparities among adults with different levels of education. Adults without a high school diploma or equivalent are 

three times as likely as those with a college education to die before age 65.16 The 

average 25-year-old with less than 12 years’ education lives almost 7 fewer years 

than someone with at least 16 years’ education.10 Children’s health is also strongly 

linked to their parents’ education.10


85792-24.eps
9 

According to Irma Elo and Samuel Preston, every additional year in educational 

attainment reduces the odds of dying by 1–3 percent.17 Ahmedin Jemal and colleagues reported that approximately 50 percent of all male deaths and 40 percent 

of all female deaths at ages 25–64 would not occur if everyone experienced the mortality rates of college graduates.18 Woolf and coauthors estimated that giving all 

U.S. adults the mortality rate of adults with some college education would save 

seven lives for every life saved by biomedical advances.19

Stark racial or ethnic differences in education and income could largely explain 

the poorer health of blacks and some other minorities. The high school dropout rate 

is 18.3 percent among Hispanics, 9.9 percent among blacks, and 4.8 percent among 

non-Hispanic whites. The proportion of Hispanic adults with less than 7 years of 

elementary school education is 20 times that of non-Hispanic whites. Black and Hispanic households earned two-thirds the income of non-Hispanic whites and were 

three times as likely to live in poverty.20 As of 2009 white households had 20 times 

the net worth of black households.21

A Web of Conditions. Education and income are elements of a web of social and 

economic conditions that affect health (and influence each other) in complex ways 

over a lifetime. These conditions include employment, wealth, neighborhood characteristics, and social policies as well as culture and beliefs about health—for example, 

the belief that diseases are ordained by fate and therefore not preventable. People 

with low education and income are more likely than their better-educated, higher 

income counterparts to lack a job, health insurance, and disposable income for medical expenses. 

Education and income are also associated with behaviors that affect health. Smoking is three times as prevalent among adults without a high school diploma than 

among college graduates.2 Similar patterns exist for other unhealthy behaviors, 

such as physical inactivity. 

THE ROLE OF NEIGHBORHOODS AND COMMUNITIES

Unhealthy behavior is partly a matter of personal choice, but extensive evidence 

documents the strong influence of the environment in which people live and 

work.5 6 11 12 One may desire to eat a healthy diet but find nutritious foods too costly 

or live too far from a supermarket that sells fresh produce.5 Parents might want 

to limit the time their children spend in front of a television or computer in favor 

of sending them outdoors for exercise, but their neighborhoods may be unsafe or 

lack playgrounds or sidewalks. 

The built environment—for example, the design of roads and pedestrian routes— 

can thwart efforts to walk or bicycle to the store or work. Poor and minority neighborhoods are often ‘‘food deserts’’ with limited access to healthy foods but numerous 

fast-food outlets.5 Schools in low-income neighborhoods often serve inexpensive processed foods and rely on revenue from vending machine contracts that promote soft 

drinks and high-calorie snacks.5


85792-25.eps
10 

But behavior is not the whole story.11 12 Distressed homes and neighborhoods can 

induce disease and contribute to disparities via pathways unrelated to behavior.8

For example, housing can expose occupants to lead and allergens. Bus depots, factories, highways, and hazardous waste sites are often situated near low-income and 

minority neighborhoods.22 Distressed communities have a notorious shortage of 

health care providers, especially in primary care. 

Social conditions are also important. Health may be compromised by the chronic 

stress of living amid multiple adverse conditions, such as poverty, unemployment, 

urban blight, and crime. Communities of color—especially minority youth—are targets of advertising that promotes the consumption of alcohol, tobacco, and high-calorie foods.5

Impoverished neighborhoods may have residents who are less able to help their 

neighbors. These neighborhoods may also have reduced social cohesion—which can 

influence health behavior; the sense of security and social well-being experienced by 

members of the community; and the ability of individuals within a community to 

join forces to advocate for needed services.11 For example, minority neighborhoods 

with poor social cohesion may be unable to mount effective political opposition to 

decisions that will affect local schools or air quality. 

Entrenched patterns reflecting long-standing disadvantage in low-income and minority neighborhoods often perpetuate cycles of socioeconomic failure. Employment 

opportunities and good schools may be scarce. Low-income residents often cannot afford to move elsewhere. Traveling across town to find a job—or a better one—or to 

reach a supermarket or doctor may be difficult if public transportation is unavailable or costly. 

BIOLOGICAL PATHWAYS TO HEALTH DISPARITIES

Sandro Galea and colleagues recently estimated that of the 2.8 million deaths in 

the United States in 2000, 245,000 were attributable to low education, 176,000 to 

racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 

and 119,000 to income inequality.23

How do these conditions claim lives? Research has identified several plausible 

pathways. For example, people living with inadequate resources often experience 

stress levels that can cause the brain to stimulate endocrine organs to produce hormones, such as cortisol and epinephrine, at levels that may alter immune function 

or cause inflammation. Repeated or sustained exposure to these substances may 

produce ‘‘wear and tear’’ on organs and precipitate chronic diseases such as diabetes 

and heart disease.11 24

Other research suggests that the most profound health effects of living conditions 

may be delayed consequences that unfold over the span of a lifetime.25 Experiences 

in the womb and early childhood, including stress, can have lasting effects that do 

not manifest themselves until late adulthood—or even in the next generation. An 

adult mother’s childhood experiences can leave a biological imprint that affects the 

neurological and mental development of her offspring. 

Even the effects of genes can be modified by the environment. New research in 

the field of epigenetics—the study of inherited changes in gene expression—suggests 

that the social and physical environment can activate the expression of genes and 

thus can determine whether a disease develops. This epigenetic makeup can be 

passed on to children and influence the occurrence of disease in more than one generation.11 Although more remains to be investigated and understood, the fact that 

many social determinants have an impact on health makes scientific sense. 

DECLINING INCOMES AND INCREASING INEQUALITY

Given that income contributes greatly to health disparities, the decline in the average income of Americans since 1999 and other signs of economic hardship are 

troubling. Between 2000 and 2009 food insecurity (defined as limited or uncertain 

access to adequate food), severe housing cost burdens (spending more than 50 percent of income on housing), and homelessness increased in the United States.20 By 

2010 the U.S. poverty rate had reached 15.1 percent, its highest percentage since 

1993.26

The gap between the rich and poor has been widening since 1968, especially recently.26 Between 2005 and 2009 the share of wealth held by the top 10 percent of 

the population increased from 49 percent to 56 percent. Over the same period, the 

average net worth of white households fell by 16 percent, from $134,992 to 

$113,149; the average net worth of black and Hispanic households fell by 53 percent 

(from $12,124 to $5,677) and 66 percent (from $18,359 to $6,325), respectively.21

The fact that the average American’s income and wealth are shrinking has important health implications. Since 1980, when the United States ranked 14th in life exVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
11 

pectancy among industrialized countries, the U.S. ranking has been declining. By 

2008 the United States ranked 25th in life expectancy, behind such countries as 

Portugal and Slovenia.27 The United States has also not kept pace with other industrialized countries in terms of infant mortality and other health indicators.27

Various explanations have been proposed, ranging from unhealthier behavior on 

the part of Americans to deficiencies in the U.S. health care system. However, a persistent question is whether U.S. health status is slipping because of unfavorable societal conditions. Other industrialized countries outperform the United States in 

education, have lower child poverty rates, and maintain a stronger safety net to 

help disadvantaged families maintain their health. 

POLICIES, MACROECONOMICS, AND SOCIETAL STRUCTURE

Economic opportunity, the vibrancy of neighborhoods, and access to education and 

income are conditions set by society, not by physicians, hospitals, health plans, or 

even the public health community. The leaders who can best address the root causes 

of disparities may be the decisionmakers outside of health care who are in a position 

to strengthen schools, reduce unemployment, stabilize the economy, and restore 

neighborhood infrastructure. Policymakers in these sectors may have greater opportunity than health care leaders to narrow health disparities. The key change agents 

may be those working in education reform to help students finish high school and 

obtain college degrees, and those crafting economic policies to create jobs and teach 

workers marketable skills. 

Even public health efforts to reduce smoking and obesity demonstrate that policy 

can often achieve more than clinical interventions. Policies to restrict indoor smoking and increase cigarette prices did more to reduce tobacco use in the past 20 years 

than relying on physicians to counsel smokers to quit.28

The most influential change agents in efforts to help Americans eat well and stay 

active may be the agencies and business interests that determine advertising messages, supermarket locations, school lunch menus, after-school and summer sports 

programs, food labels, and the built environment. Key actors include city planners, 

State officials, Federal agencies, legislatures at both the State and Federal levels, 

employers, school boards, zoning commissions, developers, supermarket chains, restaurants, and industries ranging from soda bottlers to transit companies. Initiatives 

by hospitals, medical societies, and insurers to reduce health care disparities remain 

vital, but the front line in narrowing health disparities lies beyond health care. 

THE ‘‘HEALTH IN ALL POLICIES’’ MOVEMENT

Increasingly, governments and businesses are being encouraged to consider the 

consequences to health, and to health disparities, of proposed policies in transportation, housing, education, taxes, land use, and so forth—a ‘‘health in all policies’’ 

approach. For example, a city council might replace an abandoned warehouse with 

a public park or offer tax incentives for supermarkets to locate in a ‘‘food desert’’ 

neighborhood. Health impact assessments are being commissioned to study the potential health consequences of policies concerning such diverse topics as minimum 

wage laws and freeway widening.29 The ‘‘health in all policies’’ approach has been 

adopted by individual communities, State governments, and Federal initiatives, including the interagency health promotion council established under the Affordable 

Care Act of 2010.30

This holistic approach to public policy comes at the recommendation of prestigious 

commissions sponsored by the World Health Organization,6 MacArthur Foundation,7

and Robert Wood Johnson Foundation.8 Studies in the Bay Area 31 and New York 

City,32 for example; the acclaimed 2008 documentary film Unnatural Causes 33; and 

major initiatives by the W.K. Kellogg Foundation,34 California Endowment,35 and 

Robert Wood Johnson Foundation 36 have all reinforced the message that ‘‘place 

matters.’’ Armed with a new field of research that collects data at the neighborhood 

level, communities are beginning to document and rectify local social and environmental conditions that foment health disparities. 

LINKING SOCIAL POLICY TO HEALTH DISPARITIES

Although some academics and policymakers understand the health impact of social determinants, the general public and other policymakers do not always recognize that social policy and health policy are intimately linked. Social policies are 

clearly of concern for reasons other than their health consequences. The recession 

has riveted the Nation’s attention on the need for jobs and economic growth. Politicians view the economic plight of voters as an election issue. 

The missing piece is that advocates for jobs, education, and other issues often 

overlook the health argument in making their case or calculating the return on inVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
12 

vestment. Public programs to address failing schools, disappearing jobs, and needed 

community development are under scrutiny as the fiscal crisis forces spending cuts 

to balance budgets and reduce the national debt. Defending these programs requires 

more than just making moral arguments for their retention and expansion. It requires proponents to make a solid business case, but the value proposition should 

include the medical spending avoided by having these programs in place. 

Advocates for education or jobs programs often list important benefits, such as a 

more competitive workforce, job security, and economic growth. However, they could 

gather more support, especially from policymakers concerned about medical spending, by showing that disease rates—and hence health care costs—are connected to 

education, employment, and socioeconomic well-being. 

For example, the health connection strengthens the business case for education. 

Henry Levin and colleagues reported that interventions to improve high school graduation rates among black males yield $166,000 per graduate in net savings to the 

government as a result of higher tax revenues and lower public health costs and 

crime rates.37 Muennig and Woolf estimated that the health benefits of reducing elementary school classroom sizes yield $168,000 in net savings per high school graduate.38 Robert Schoeni and coauthors estimated that giving all Americans the 

health status of college-educated adults would generate more than $1 trillion per 

year in health benefits.39

Making the connection between social determinants and medical spending heightens the relevance of social policy to a pressing national priority: the spiraling costs 

of health care, which have alarmed elected officials, employers, health plans, and 

the public. Whether any proposed remedy—from malpractice reform to the implementation of accountable care organizations—can bend the cost curve remains uncertain. 

The gravitational pull of health care has kept the policy focus on reorganizing 

care, implementing information technology, and reforming the payment system, 

with less consideration of issues outside of medicine—even though they might curb 

the flow of patients into the system and reduce spending more dramatically. Bobby 

Milstein and coauthors recently calculated that expanding health insurance coverage and improving health care would do less to save lives and control medical 

spending than policies to improve environmental conditions and promote healthier 

behavior.40

Remedies outside of health care can both reduce the cost of care and ameliorate 

health disparities. An example is diabetes, a disease of rising prevalence and costs. 

Diabetes occurs among adults without a high school diploma at twice the rate observed among college graduates.2 This disparity should speak volumes to policymakers seeking to control spending on this disease—and those tempted to cut education budgets to finance health care. 

WHY THIS MATTERS NOW

These issues need attention now, for four reasons. First, this is a time of worsening socioeconomic conditions and rising inequality, fomented by the recession and 

economic policies. Higher disease burden, greater medical spending, and widened 

disparities could result. 

The programs that could cushion stresses on children and families are 

now vulnerable to budget reductions. 

Second, exposing children to today’s adverse social conditions has ramifications for 

the health of tomorrow’s adults. It has already been predicted that this generation 

could, for the first time in U.S. history, live shorter lives than its predecessors because of the obesity epidemic.41 Children’s exposure to worsening socioeconomic conditions from fetal life through adolescence could alter the trajectory of their health, 

making them more likely to develop disease later in life.25 These outcomes could intensify demands on a health care system that is already too costly to sustain. 

Third, the very programs that could cushion stresses on children and families are 

now vulnerable to proposed budget reductions. Programs that help people get an 

education, find a job that can lift a family out of poverty, or provide healthy food 

and stable housing are being eliminated to balance budgets. This strategy, however, 

could backfire if it precipitates disease, drives more patients into the health care 

system, and increases medical spending. 

Fourth, presidential and congressional elections are fast approaching, and many 

politicians are eager to exhibit their fiscal conservatism by reducing the size of government and eliminating social programs. The zeal to cut spending may discourage 

thoughtful consideration of how such cuts might expose voters to greater illness or 

harm the economy. 

13 

It may be naı ̈ve to hope that elected officials will rise above reelection concerns 

to address outcomes that will outlast their term in office and promote the greater 

good. It may be more realistic to hope that the public and policymakers will begin 

to connect the dots and see health as a by-product of the environment in which 

Americans live. They might come to see that decisions about child care, schools, 

jobs, and economic revitalization are ultimately decisions about health—and the 

costs of health care. 

Social issues lack quick and easy solutions. Politics surrounds questions of how 

best to educate children and improve the economic well-being of American families. 

However, scientific knowledge now makes it clear that the current movement to 

shrink investments in these areas has implications for public health and the costs 

of medical care. Fiscally prudent politicians (and voters) who learn about the medical price tag associated with austere economic and social policies may question the 

logic of ‘‘cutting spending’’ in ways that ultimately increase costs. 

For the health equity movement, the challenge is to clarify this connection for policymakers and to not focus exclusively on how physicians and hospitals can reduce 

disparities. Equitable health care is essential, but health disparities will persist— 

as they have for generations—until attention turns to the root causes outside the 

clinic. 

Note: The authors thank the research staff of the Virginia Commonwealth University Center on Human Needs (Project on Societal Distress) and of the Robert 

Wood Johnson Foundation Commission to Build a Healthier America for source data 

cited in this article. The authors also thank Karen Simpkins for assistance in producing the exhibits. The Project on Societal Distress was funded by the W.K. Kellogg Foundation (Grants P3008553, P3011306, and P3015544). 

ENDNOTES

1. Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies 

Press; 2003. 

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feature on death and dying. Hyattsville (MD): NCHS; 2011. 

3. Satcher D, Fryer GE, Jr., McCann J, Troutman A, Woolf SH, Rust G. What 

if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. 

Health Aff (Millwood). 2005;24(2):459–64. 

4. Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S. Racial and 

ethnic disparities in the VA health care system: a systematic review. J Gen Intern 

Med. 2008;23(5): 654–71. 

5. Woolf SH, Dekker MM, Byrne FR, Miller WD. Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J Prev Med. 

2011;40(1 Suppl 1):S38–47. 

6. Commission on Social Determinants of Health. Closing the gap in a generation: 

health equity through action on the social determinants of health; final report of the 

Commission on Social Determinants of Health. Geneva: World Health Organization; 

2008. 

7. John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. Reaching for a healthier life: facts on socieconomic status and health in the United States. Chicago (IL): MacArthur Foundation; 2008. 

8. Braveman P, Egerter S. Overcoming obstacles to health. Princeton (NJ): Robert 

Wood Johnson Foundation; 2008. 

9. Link BG, Phelan J. Social conditions as fundamental causes of disease. J 

Health Soc Behav. 1995;35:80–94. 

10. Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic 

disparities in health in the United States: what the patterns tell us. Am J Public 

Health. 2010;100 (Suppl 1):S186–96. 

11. Braveman P, Egerter S, Williams D. Social determinants of health: coming of 

age. Annu Rev Public Health. 2011;32:381–98. 

12. Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and 

mechanisms. Annu Rev Public Health. 2008;29:235–52. 

13. Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, Kennedy M. The 

fall and rise of U.S. inequities in premature mortality: 1960–2002. PLoS Med. 

2008;5(2):e46. 

14. Woolf SH, Jones RM, Johnson RE, Phillips RL, Jr., Oliver MN, Vichare A. 

Avertable deaths associated with household income in Virginia. Am J Public Health. 

2010;100(4):750–5. 

14 

15. Muennig P, Fiscella K, Tancredi D, Franks P. The relative health burden of 

selected social and behavioral risk factors in the United States: implications for policy. Am J Public Health. 2010;100(9):1758–64. 

16. Heron M, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. 

Deaths: final data for 2006. Nat Vital Stat Rep. 2009;57(14):1–134. 

17. Elo IT, Preston SH. Educational differentials in mortality: United States 

1979–1985. Soc Sci Med. 1996;42(1):47–57. 

18. Jemal A, Thun MJ, Ward EE, Henley SJ, Cokkinides VE, Murray TE. Mortality from leading causes by education and race in the United States, 2001. Am 

J Prev Med. 2008;34(1):1–8. 

19. Woolf SH, Johnson RE, Phillips RL Jr., Philipsen M. Giving everyone the 

health of the educated: an examination of whether social change would save more 

lives than medical advances. Am J Public Health. 2007; 97(4):679–83. 

20. Project on Societal Distress [home page on the Internet]. Richmond (VA): Virginia Commonwealth University, Center on Human Needs; [cited 2011 Aug 25]. 

Available from: http://www.societaldistress.org/. 

21. Taylor P, Kochhar R, Fry R, Velasco G, Motel S. Wealth gaps rise to record 

highs between whites, blacks, and Hispanics. Washington (DC): Pew Research Center; 2011. 

22. Brulle RJ, Pellow DN. Environmental justice: human health and environmental inequalities. Annu Rev Public Health. 2006;27:103–24. 

23. Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. Am J Public Health. 

2011;101(8):1456–65. 

24. McKewen B, Gianaros PJ. Central role of the brain in stress and adaptation: 

links to socioeconomic status, health, and disease. Ann N Y Acad Sci. 

2010;1186:190–222. 

25. Cohen S, Janicki-Deverts D, Chen E, Matthews KA. Childhood socioeconomic 

status and adult health. Ann N Y Acad Sci 2010;1186:37–55. 

26. DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2010 [Internet]. Washington (DC): Census Bureau; 2011 Sep [cited 2011 Sep 21]. (Current Population Reports). Available from: 

http://www.census.gov/prod/2011pubs/p60–239.pdf. 

27. Organization for Economic Cooperation and Development. OECD health data 

2011—frequently requested data [Internet]. Paris: OECD; 2011 Jun 30 [cited 2011 

Aug 25]. [Available from: http://www.oecd.org/dataoecd/52/42/48304068.xls#’LE 

Total population at birth’!A1.] 

28. Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. 

Annu Rev Public Health. 2006;27:341–70. 

29. Cole BL, Fielding JE. Health impact assessment: a tool to help policymakers 

understand health beyond health care. Annu Rev Public Health. 2007;28:393–412. 

30. National Prevention, Health Promotion, and Public Health Council. 2010 annual status report [Internet]. Washington (DC): Department of Health and Human 

Services; 2010 Jul 1 [cited 2011 Aug 25]. Available from: http://www.hhs.gov/ 

news/reports/nationalprevention2010report.pdf. 

31. Beyers M, Brown J, Cho S, Desautels A, Gaska K, Horsley K, et al. Life and 

death from unnatural causes: health and social inequity in Alameda County; executive summary [Internet]. Oakland (CA): Alameda County Department of Health; 

2008 Apr [cited 2011 Sep 21]. Available from: http://www.barhii.org/press/ 

download/unnaturallcauseslreport.pdf. 

32. Myers C, Olson C, Kerker B, Thorpe L, Greene C, Farley T. Reducing health 

disparities in New York City: health disparities in life expectancy and death. New 

York (NY): New York City Department of Health and Mental Hygiene; 2010. 

33. National Minority Consortia of Public Television. Unnatural causes . . . is inequality making us sick? [DVD]. San Francisco (CA): California Newsreel; c2008. 

34. W.K. Kellogg Foundation. Place matters: empowering local leaders to build 

public will to address community needs [Internet]. Battle Creek (MI): WKKF; [cited 

2011 Sep 21]. Available from: http://www.wkkf.org/what-we-support/racial-equity/ 

stories/empowering-local-leaders-to-build-public-will-to-address-communityneeds.aspx. 

35. California Endowment. Building healthy communities: California living 2.0 

[Internet]. Los Angeles (CA): The Endowment; [cited 2011 Sep 21]. Available from: 

http://www.calendow.org/Article.aspx?id=134 &ItemID=134. 

36. Robert Wood Johnson Foundation. Place and health: why conditions where we 

live, learn, work, and play matter [Internet]. Princeton (NJ): RWJF; [cited 2011 Sep 

21]. Available from: http://rwjf.org/vulnerablepopulations/product.jsp?id=72288. 

15 

* Note: Author Affiliations: Virginia Commonwealth University Center on Human Needs, 

Virginia Commonwealth University, Richmond. 

† Note: Corresponding Author: Steven H. Woolf, MD, MPH, Center on Human Needs, Virginia Commonwealth University, West Hospital, 1200 East Broad St, PO Box 980251, Richmond, VA 23298–0251 (swoolf@vcu.edu). 

37. Levin HM, Belfield C, Muennig P, Rouse C. The public returns to public educational investments in African-American males. Econ Educ Rev. 2007;26(6):699– 

708. 

38. Muennig PA, Woolf SH. Health and economic benefits of reducing the number 

of students per classroom in U.S. primary schools. Am J Public Health. 2007;97 

(11):2020–7. 

39. Schoeni RF, Dow WH, Miller WD, Pamuk ER. The economic value of improving the health of disadvantaged Americans. Am J Prev Med. 2011;40(1 Suppl 

1):S67–72. 

40. Milstein B, Homer J, Briss P, Burton D, Pechacek T. Why behavioral and environmental interventions are needed to improve health at lower cost. Health Aff 

(Millwood). 2011;30 (5):823–32. 

41. Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, et 

al. A potential decline in life expectancy in the United States in the 21st century. 

N Engl J Med. 2005;352 (1):1138–45. 

COMMENTARY 

PUBLIC HEALTH IMPLICATIONS OF GOVERNMENT SPENDING REDUCTIONS * 

(By: Steven H. Woolf, MD, MPH) † 

ACROSS THE UNITED STATES, CONCERNS OVER BUDGET deficits and a weak economy have prompted Federal, State, and local governments to propose controversial 

spending reductions to balance their budgets. Debates and protests incited by these 

decisions dominate the news, but what is their relevance to medicine? The reflexive 

answer might be that government spending policies are relevant if they compromise 

health care services, essential public health programs, or biomedical research. However, the biggest threat to public health may come from funding cuts outside the 

health sector. Namely, budget decisions that affect basic living conditions—removing 

opportunities for education, employment, food security, and stable neighborhoods— 

could arguably have greater disease significance than disruptions in health care. 

Health status is determined by more than health care. Education, income, and the 

neighborhood environment exert great influence on the development of disease—perhaps more than interventions by physicians or hospitals.1 Consider the role of education. In 2007, adults with a bachelor’s degree were four times less likely to report 

fair or poor health than those without a high school education.2 The prevalence of 

diabetes among adults without a high school diploma was 13.2 percent, more than 

double the prevalence among adults with a bachelor’s degree (6.4 percent).2 In 

2008–9, the risk of stroke was 80 percent higher among adults who lacked a high 

school diploma than among those with some college education.3 At age 25, life expectancy is at least 5 years longer among college graduates than among those who 

did not complete high school.4 Multiple factors explain the health disparity associated with education. Educational attainment is inversely associated with smoking 

and obesity,3 but it is also a pathway to better jobs, benefits (including health insurance), and financial security—each of which conveys health advantages. 

Families with financial insecurity face hardships that often take priority over 

health concerns. These families tend to eat poorly, forgo exercise, and skip medications to stretch their budget. Low incomes force many to live in unhealthy housing 

or in struggling or insecure neighborhoods. Such neighborhoods tend to have limited 

access to medical care, nutritious groceries, and safe places to exercise and an oversupply of fast foods, liquor stores, pollution, and crime.5 A life of hardships is associated with higher rates of stress and depression.2

The association between income and health applies to everyone, not just those 

who are poor. Middle-class individuals have lower life expectancy and worse health 

status than those who are wealthy.4 Rich or poor, individuals facing more difficult 

financial circumstances tend to defer clinical care and allow complications to linger. 

Disadvantaged patients present to physicians in more advanced stages of disease 

that are more difficult and costly to treat and are often less survivable.6 In sum, 

budget policies that impose financial strain on families or curtail educational opportunities could, in time, cause greater morbidity, mortality, and costs—all of which 

are problematic on moral and economic grounds. 

16 

The moral issue is clear: it is unsettling to adopt policies that will induce a higher 

rate of premature deaths or greater disease or disability. Such policies tend to disproportionately affect those who are poor or who are members of racial or ethnic 

minority groups, and they often affect children as well. These policies would be 

soundly rejected if health outcomes and ethics were the only considerations, but policymakers must also contend with economic and political realities. 

The core argument of fiscal conservatives is that difficult budget decisions and fiscal discipline are necessary for the economy—a worthy principle for many spending 

areas. However, fiscal discipline loses its logic when spending reductions lead to 

greater illness and thereby increase health care costs. Any policy that increases disease burden is a threat to the economy because medical spending is so costly to government and employers. Medicare, Medicaid, and children’s health insurance consume 23 percent of the Federal budget.7 Health care costs are complicating efforts 

to balance State budgets, operate businesses, and compete in the global marketplace. The need to control medical cost inflation is a mounting national priority, one 

that argues against budgetary policies that would increase morbidity, heighten demand on the system, and drive up medical spending. 

That unwanted scenario is a potential outcome of the more austere budget cuts 

under current consideration, many of which would impose economic strain on families, weaken support for education, and allow neighborhood living conditions to become more unhealthy. The effect of these conditions on health, relative to medical 

care, is often underestimated. According to one estimate, giving every adult the mortality rate of those who attend college would save seven times as many lives as 

those saved by biomedical advances.8 It has been estimated that 25 percent of all 

deaths in Virginia between 1990 and 2006 might not have occurred if the entire 

population had experienced the mortality rate of those who lived in the State’s most 

affluent counties and cities.9

In the United States, the adverse socioeconomic conditions that are linked with 

mortality have become more prevalent in the past decade, especially with the economic recession. Between 2007 and 2009, median household income decreased from 

$51,965 to $49,777, down from a peak of $52,388 in 1999.10 Between 2000 and 2009, 

the number of households with food insecurity increased from 10 million to 17 million.10 The percentage of individuals with severe housing costs burdens (spending 

more than 50 percent of their income on housing) increased from 13 percent in 2001 

to more than 18 percent in 2009.10 The number of homeless individuals in families 

requiring shelters or transitional housing increased from 474,000 in 2007 to 535,000 

in 2009.10 The poverty rate increased from 11.3 percent in 2000 to 14.3 percent in 

2009, its highest percentage since 1994 and the largest absolute number on 

record.10

It is reasonable to predict that the population’s exposure to these conditions will 

eventually result in some increase in the prevalence and severity of major illnesses, 

a trend that would place greater demands on the health care system. Already, emergency departments and hospitals are noting the recession’s effect on admissions for 

uncontrolled diabetes and heart failure. Lasting effects may take years to document. 

Many of today’s children could endure greater illness decades hence and a shorter 

life expectancy because they grew up during current conditions. This dismal forecast 

bears attention from health care leaders, who must prepare capacity plans for the 

wave of patients that a distressed economy would push into the system, and from 

politicians and economists, who must consider how that care will be financed by a 

system already too expensive to sustain. 

Amid these conditions, it is fair to ask whether now is the right time to cut programs that sustain living conditions for good health and that protect U.S. residents 

from losing their jobs, income, education, and food. The answer may be disappointing, as the downstream effects on illness and spending may not be enough 

to outweigh the budgetary pressures of the present, but the question should at least 

be posed and the tradeoffs discussed. Too often, policymakers and the public fail to 

recognize the connection between social and health policies, and this seems true 

again as proponents and critics of current budget reforms wage their debate. When 

policies could claim lives, exacerbate illnesses, and worsen the economic crisis, these 

ramifications should at least be discussed. 

Note: Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none 

were reported. 

Note: Funding/Support: This Commentary cites research by the Virginia Commonwealth University Center on Human Needs that was funded by the Robert 

Wood Johnson Foundation (grant 63408) and the statistics were compiled by the 

Center on Human Needs’ Project on Societal Distress, which is supported by the 

W.K. Kellogg Foundation (grants P3008553, P3011306, and P3015544). 

17 

Note: Role of the Sponsor: The W.K. Kellogg Foundation and Robert Wood 

Johnson Foundation had no role in the preparation, review, or approval of the 

manuscript. 

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18 

Senator SANDERS. Thank you very much, Dr. Woolf. 

Senator Warren, did you want to introduce Dr. Berkman? 

Senator WARREN. I do, Mr. Chairman. Thank you very much. 

It is my honor to introduce Dr. Lisa Berkman, the Thomas Cabot 

Professor of Public Policy and Epidemiology, and the director of the 

Harvard Center for Population and Development Studies at the 

Harvard School of Public Health. Dr. Berkman is a social epiVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6601 S:\DOCS\22267.TXT DENISE

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19 

demiologist who examines the impact of social and policy factors on 

health outcomes. 

Dr. Berkman began her career at Northwestern University, 

where she received her bachelor’s in sociology, later attended the 

University of California Berkeley where she earned both her master’s and her doctorate in epidemiology. Before joining the faculty 

at Harvard, she spent 16 years as a professor at the Yale School 

of Medicine. 

Dr. Berkman’s research, both in America and internationally, 

has helped us better understand the role that social inequality 

plays in people’s health. She has authored or co-authored 275 publications in peer-reviewed literature and numerous book chapters, 

and is a member of the Institute of Medicine. 

I am so pleased that Dr. Berkman is with us here today, and I 

am looking forward to an engaging conversation with her. 

Senator SANDERS. Dr. Berkman, thanks very much for being 

here. Please begin. 

STATEMENT OF LISA BERKMAN, Ph.D., DIRECTOR OF THE 

HARVARD CENTER FOR POPULATION AND DEVELOPMENT 

STUDIES AND THOMAS D. CABOT PROFESSOR OF PUBLIC 

POLICY AND EPIDEMIOLOGY, HARVARD UNIVERSITY, CAMBRIDGE, MA 

Ms. BERKMAN. Chairman Sanders, Senator Warren, Senator 

Baldwin, and other members of the committee, thank you for this 

invitation to testify. You have chosen a very provocative title for 

this hearing. It calls for a straightforward response that outlines 

more than the situation, but also includes potential solutions. 

First, I am going to describe, very briefly, trends in life expectancy and the unequal distribution of lists of death by socioeconomic 

status in the United States, then I will go to some practical options 

for improving the Nation’s health. I will focus on work policy particularly here because it is an area in which the Federal and State 

Governments have a role in shaping policies that would reduce 

health disparities. 

First, as we have said, U.S. life expectancy has lost ground compared to other Nations in the last decades, especially for women. 

I was a member of the National Academy of Science’s panel on longevity trends. It found that the United States ranked at the bottom 

of 21 industrialized, developed Nations. These low rankings are 

particularly striking for the poor and for women. 

Of most concern is the widening gap and the risk of death between those at the bottom and those at the top. This gap has widened over the past 25 years. For instance, in 2007, the death rate 

for men without a high school education was 7 per 100; it was 2 

per 100 for those with a college education. This corresponds to a 

31⁄2-fold increased risk for those less-educated men. This risk has 

grown substantially over the last 25 years. 

Among women, the patterns are even more troubling. For lesseducated women, the risk of dying actually increased, as you noted, 

in absolute terms during this time. Most striking, this pattern 

holds even if we only look at white women in the United States. 

Now, using the public health framework, I want to show how 

labor policies and practices can make a difference in American’s 

20 

health. Although health insurance and access to medical care can 

help reduce risks of financial catastrophe, and also help cure disease once it occurs, healthcare alone cannot prevent disease. It is 

like aspirin and headaches. Aspirin can cure headaches, but headaches are not caused by lack of aspirin; they are not aspirin deficiency diseases. 

To reduce headaches, we need to focus on the cause of the headache. For this same reason, we need to look at what causes these 

high rates of dying among the poor and less-educated. 

So turning to work, then. A number of studies on the relationship between work and health show that employment almost always associates with better health. These associations last well 

into old age and relates to reduced mortality risk, as well as to the 

maintenance of cognitive and physical functioning. 

Here are three specific work-related policies that promise to improve health, especially for low wage earners and their families. 

No. 1, the Earned Income Tax Credit program. EITC is associated 

with improvement in infant health and decreases in smoking 

among mothers. Getting the EITC means that your baby, on average, will be 16 grams heavier. To put that in context, it is equal 

to about one-third of the association between birth weight and having a mother with a high school degree. EITC reduces the odds of 

maternal smoking by 5 percent and increases mother’s odds of 

working and increases her wages. 

No. 2, recent evidence on maternity leave policies in the United 

States and Europe suggests that protecting employment among expectant and recent mothers leads to better long-term labor-market 

outcomes including wage level and growth, career prospects, labor 

market attachment, and employability. Mounting evidence suggests 

maternity leave is health-promoting for infants and for their mothers throughout their lives. 

No. 3, work-family practices. In a study that we did of employees 

in long term care facilities—which is primarily a low wage working 

group in a very highly regulated industry—we found that when 

managers were attentive to work-family issues, their employees 

were half as likely to have cardiovascular risks compared to workers who have less family friendly bosses. Specifically, these employees were less likely to be overweight, they have lower blood pressure, lower diabetes. 

The health effects that I have described here are not counted in 

the current cost benefit metrics of these policies, so we dramatically underestimate the real benefits that they have. Our labor 

policies challenge working-class families to remain simultaneously 

committed to work and to family. Over half of low-wage earners 

lack sick leave to take care of family. I could give you more policies 

that would help the health of our low-income working families, but 

I will stop here. 

The EITC, pro-family work policies and practices, and parental 

leave are just three examples of policies that impact the health of 

low-income working families. 

Thank you very much. 

[The prepared statement of Ms. Berkman follows:] 

21 

PREPARED STATEMENT OF LISA F. BERKMAN, PH.D. 

Chairman Sanders, Senator Burr and members of the committee, thank you for 

the invitation to testify. 

I will discuss two issues today. First, I will describe trends in U.S. life expectancy 

and the unequal distribution of mortality risk by socioeconomic status in the United 

States. Second, I will elaborate on options for improving the Nation’s health, especially related to labor policies for low-wage workers. I will frame our options for improving health in terms of what we can do to create a healthy population and prevent disease. 

First, U.S. overall life expectancy—that is the expected number of years someone 

born today can expect to live—has lost ground compared to that of other nations 

in the last decades, especially for women. I was a member of a recent National 

Academy of Science Panel on diverging trends in longevity. It found that the United 

States ranked at the bottom of 21 developed, industrialized nations 1 and poor 

rankings were particularly striking for women. In the 1980s our rankings were in 

the middle of OECD countries in this study. While it is true that LE improved during this time from by 5.6 years for men and 3.6 years for women, other countries 

gained substantially more in terms of life expectancy, leaving us behind. Furthermore, almost all those gains were concentrated among the most socioeconomically 

advantaged segments of the U.S. population. And they were more substantial for 

men than for women. The poorest Americans experienced the greatest health disadvantage compared to those in other countries.2 3 At a recent NIH conference, the 

discussion was focused on the steps required for the United States to reach just the 

OECD average in the next 20 years—not even the top. It seems we have given up 

on achieving better than average health. 

More concerning is the widening gap in mortality—or risk of death—between 

those at the bottom and at the top in the United States. These gaps have widened 

over the last 25 years. These patterns are evident whether we look at education, 

income or wealth differentials, but because the evidence is clearest that education 

itself is causally linked to health and functioning.4 5 I will focus on these associations. For instance, the mortality for men with less than a high school education 

in 2007, was about 7 per 100. For those with 16 years or more of education, the 

rate was less than 2 per 100. This corresponds to a 31⁄2-fold risk of dying in 2007, 

compared to 2.5 times the risk in 1993. For less-educated women, their mortality 

risk actually increased absolutely during this time giving rise to an increased risk 

from 1.9 to 3 in 2007 6 and this pattern holds even if we confine our analyses to 

white women.7 While it is true that fewer adults are in the less-educated pool in 

later years, giving rise to questions about selection issues, it is also true that adults 

in the highest educated categories have grown over this same time suggesting increased compositional heterogeneity in these groups. Overall while selection into 

education level occurs, it accounts for only a small part of this widening gap. 

While mortality gaps in socioeconomic status have existed for centuries, the magnitude of these differences has grown substantially over time in the United States. 

These widening disparities suggest that either disparities in the underlying determinants of illness and mortality have also been growing over time or that support 

to buffer these stressful conditions has changed. In either case, while we may not 

be able to eliminate health disparities, the fact that the size of the risks varies so 

much suggests that such large inequalities are not inevitable or innate and, gives 

hope that there are ways to reduce the burden of illness for our most vulnerable 

citizens. 

Now, using a public health framework, I discuss the identification of health risks. 

While health insurance and access to medical care help reduce risks of financial catastrophe and can improve the health of those suffering from illness, health care 

alone cannot ensure good health and prevent the onset of disease. To illustrate this 

point, we can think of the aspirin/headache analogy. ‘‘While Aspirin cures a headache, lack of aspirin is not the cause of headaches.’’ Headaches are not caused by 

aspirin deficiency—to reduce headaches we need to focus on what causes headaches. 

This is what prevention and public health approaches offer. Obviously it would be 

better to maintain health than have to treat illness once it occurs. Treatments are 

financially very costly, but more importantly, waiting to treat disease is costly to 

the quality of lives of all Americans. 

What would be required to produce better health among Americans and reduce 

socioeconomic disparities in health? What do poor socioeconomic conditions influence 

that could cause such increased risk across such a huge number of diseases across 

all age groups from the infancy to old age? You are all probably thinking about the 

usual suspects—smoking, poor diet, and lack of exercise. I’m not going to focus on 

these usual suspects today, not because I don’t believe they pose substantial risks 

22 

to health, but because we know that it is very hard to change these behaviors without considering the social and economic conditions that shape them. These social 

and economic conditions are fundamental determinants of health because they influence so many behaviors and access to so many opportunities and resources. Change 

here will influence a number of channels leading to increased mortality risk. In my 

testimony I will focus on one of these conditions relating to participation in the 

labor market. 

Several years ago, I embarked on a study to assess the relationships between employment, family dynamics and health. We found that employment was almost always associated with better health. These associations lasted well into old age. 

Women who had the lowest mortality risk in later adulthood had spent some time 

out of the labor market (a few years over the career path) but maintain steady labor 

force participation for most of their lives until retirement. Drawing on data from the 

Health and Retirement Study, we find that among married mothers, those who 

never worked had an age-standardized mortality rate of 52.6 whereas mothers who 

took some time off when their children were young but who later joined the workforce and mortality rates of around 40. Single mothers who never worked had the 

highest mortality of 98 compared to 68 for single mothers who worked. 

Selection into the labor force may account for some of this association, but more 

experimental evidence confirms the positive health benefits of working especially for 

low-income women and men. 

For example, the EITC is associated with improvements in infant health and decreases in smoking among mothers.8 In an analysis of State variation in the Earned 

Income Tax Credits (EITCs) between 1980 and 2002, Strully finds that EITC’s increase birth weights by, on average, 16 grams. To put that in context, it is equal 

to about a third of the association between birth weight and having a mother with 

a high school degree. Living in State with EITC reduces the odds of maternal smoking by 5 percent, and increases mother’s odds of working and increases her wages 

and salary. 

Recent evidence from several studies of maternity leave policies in the United 

States and Europe suggests that, by protecting employment among mothers in the 

period around birth, maternity leave leads to better long-term labor market outcomes after maternity including wage level and growth, career prospects, labor market attachment and employability.9 10 11 12 Thus not only may maternity leave benefit children and mothers around the period of birth, they may have long-term benefits for mothers that extend for decades in later adulthood. 

In an observational study of employees in long-term care facilities, we found that 

workers whose managers were attentive to work-family issues had half the cardiovascular risks as assessed by objective biomarkers from blood or clinical exam and 

healthier patterns of sleep compared to those who worked for less family-friendly 

managers.13 Specifically, employees whose managers maintained family-friendly 

practices were less likely to be overweight, had lower risk of diabetes and lower 

blood pressure. Based on objective measures of sleep using actigraphy monitors, 

these same employees slept almost 30 minutes more per night than their counterparts. For nurses and certified nursing assistants in low- and middle-wage jobs, 

these are important risks to which they were exposed. 

Such research suggests that labor policies and practices that support men and 

women in the labor force and especially help those with caregiving obligations are 

health promoting. These policies and practices have health effects that are not often 

‘‘counted’’ as we think about their costs and benefits. Men and women will need opportunities and flexibility and schedule control to enter and remain in the labor 

force given the inevitability of having to care for children, parents, or partners at 

some point in time. Our goal for women should be to enable them to be successful 

in their productive as well as reproductive lives. Right now, we make this very difficult. Our labor policies challenge working class families to remain committed to 

work and to their families. For example, over half (54 percent) of low-wage earners 

lack sick leave or vacation to take care of families and around 30 percent of middleincome families lack such leave.14 Even fewer have parental leave. 

We have shown that we can identify the socioeconomic disparities in health with 

some precision. Solutions that help to maintain low- and working-class men and 

women in the paid labor force have clear health benefits. The EITC, pro-family work 

policies and practices and parental leave are examples of polices that impact health 

of low-income working families. Targets enabling adults to participate in the paid 

labor force while not risking the health and well-being of their family members 

show particular value. Metrics for evaluating social and economic policies do not 

currently include health metrics. The health spillovers of such policies would increase the benefits of such policies in any cost-benefit equations. We want to ensure 

23 

that Americans, particularly those living in poverty and working-class families 

aren’t robbed of healthy years of life. 

REFERENCES

1. National Research Council (US) Panel on Understanding Divergent Trends in 

Longevity in High-Income Countries; Crimmins EM, Preston SH, Cohen B, editors. 

Explaining Divergent Levels of Longevity in High-Income Countries. Washington 

(DC): National Academies Press (US); 2011. Available from: http:// 

www.ncbi.nlm.nih.gov/books/NBK62369/. 

2. Avendano M, Glymour MM, Banks J, Mackenbach JP. Health disadvantage in 

U.S. adults aged 50 to 74 years: a comparison of the health of rich and poor Americans with that of Europeans. Am J Public Health. 2009 Mar;99(3):540–8. doi: 

10.2105/AJPH.2008.139469. Epub 2009 Jan 15. PubMed PMID: 19150903; PubMed 

Central PMCID: PMC2661456. 

3. Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the 

United States and in England. JAMA. 2006 May 3;295(17):2037–45. PubMed PMID: 

16670412. 

4. Lleras-Muney, Adriana. ‘‘The Relationships Between Education And Adult Mortality In The United States,’’ Review of Economic Studies, 2005, v72(250,Jan), 189– 

221. 

5. Glymour MM, Kawachi I, Jencks CS, Berkman LF. Does childhood schooling 

affect old-age memory or mental status? Using State schooling laws as natural experiments. J Epidemiol Community Health. 2008 Jun;62(6):532–7. doi: 10.1136/ 

jech.2006.059469. PubMed PMID: 18477752; PubMed Central PMCID: 

PMC2796854. 

6. Ma J, Xu J, Anderson RN, Jemal A (2012) Widening Educational Disparities 

in Premature Death Rates in Twenty Six States in the United States, 1993–2007. 

PLoS ONE 7(7): e41560. doi:10.1371/journal.pone.0041560. 

7. Montez JK, Hummer RA, Hayward MD, Woo H, Rogers RG. Trends in the Educational Gradient of U.S. Adult Mortality from 1986 to 2006 by Race, Gender, and 

Age Group. Res Aging. 2011 Mar;33(2):145–171. PubMed PMID: 21897495; PubMed 

Central PMCID: PMC3166515. 

8. Strully KW, Rehkopf DH, Xuan Z. Effects of Prenatal Poverty on Infant 

Health:State Earned Income Tax Credits and Birth Weight. Am Sociol Rev. 2010 

Aug 11;75(4):534–562. PubMed PMID: 21643514; PubMed Central PMCID: 

PMC3104729. 

9. Brugiavini, A., Pasini, G. and E. Trevisan (2013) ‘‘The direct impact of maternity benefits on leave taking: evidence from complete fertility histories’’, Advances 

in life course research, 18: 46–67. 

10. Rossin M. The effects of maternity leave on children’s birth and infant health 

outcomes in the United States. J Health Econ. 2011 Mar;30(2):221–39. doi: 10.1016/ 

j.jhealeco.2011.01.005. Epub 2011 Jan 18. PubMed PMID: 21300415; PubMed Central PMCID: PMC3698961. 

11. Rossin-Slater M, Ruhm CJ, Waldfogel J. The effects of California’s paid family 

leave program on mothers’ leave-taking and subsequent labor market outcomes. J 

Policy Anal Manage. 2013;32(2):224–45. PubMed PMID: 23547324; PubMed Central 

PMCID: PMC3701456. 

12. Ruhm CJ. Policies to assist parents with young children. Future Child. 2011 

Fall;21(2):37–68. PubMed PMID: 22013628; PubMed Central PMCID: PMC3202345. 

13. Berkman LF, Buxton O, Ertel K, Okechukwu C. Managers’ practices related 

to work-family balance predict employee cardiovascular risk and sleep duration in 

extended care settings. J Occup Health Psychol. 2010 Jul;15(3):316–29. doi: 10.1037/ 

a0019721. PubMed PMID: 20604637; PubMed Central PMCID: PMC3526833. 

14. Heymann SJ. The Widening Gap: Why Working Families Are in Jeopardy and 

What Can Be Done About It. New York: Basic Books, 2000. 

Senator SANDERS. Thank you very much, Dr. Berkman. 

Senator Burr is unable to be with us this morning, but his guest 

is Dr. Nicholas Eberstadt, who is the Henry Wendt Chair in Political Economy at the American Enterprise Institute. He is also a 

senior advisor to the National Bureau of Asian Research, a member 

of the Visiting Committee at the Harvard School of Public Health, 

and a member of the Global Leadership Council at the World Economic Forum. He researches and writes extensively on economic 

development, foreign aid, global health, demographics, and poverty. 

24 

Dr. Eberstadt, thanks very much for being with us. 

STATEMENT OF NICHOLAS EBERSTADT, Ph.D., MPA, M.Sc., 

HENRY WENDT CHAIR IN POLITICAL ECONOMY, AMERICAN 

ENTERPRISE INSTITUTE, WASHINGTON, DC 

Mr. EBERSTADT. Mr. Chairman, Senators Warren, Baldwin, distinguished co-panelists, and guests. 

It is an honor to be here. My testimony focuses upon the exceptions to the established generalization that better education, better 

health access, and better income result in better health outcomes. 

Nobody disputes this, but the predictive power of those generalizations should be appreciated, because it is limited. 

In my testimony, I show a number of tables which make this argument more clearly than perhaps one can in a brief period of time. 

If we look at Table 1 in my testimony, I show poverty rates, percentages of adults without high school degrees, GINI coefficients, 

percentages with no health insurance, and age-adjusted percentages of adults 18 or over with no healthcare visits in the previous 

12 months for non-Hispanic whites, also known as Anglos, for 

Asian Pacific Americans, for Black non-Hispanic African-Americans, for Hispanics, and for the country as a whole. 

Now what you will see in this chart is that by all of these indicators, by far the most advantaged group in the United States are 

the Anglos, lower poverty rates, lower percentages of adults without high school education, lower GINI coefficients for family income, lower percentages without health insurance, and lower percentages who have never been to a doctor or another professional 

in the last 12 months. 

One would think on the basis of what we know that these Anglos 

would have better than average mortality for the United States as 

a whole. They do not. In fact, their mortality level, age standardized, is slightly worse than the Nation as a whole. 

If one takes a look at the group which seems to be most disadvantaged by these metrics, which would be Latinos, their age 

standardized mortality is not higher than the national average. In 

fact, it is 25 percent lower. We should want to understand why this 

paradox occurs. 

If we look at Figure 5 in my testimony, which shows life expectancy in the County of Los Angeles, America’s largest, most populous county, the most privileged group in terms of poverty rate 

would be the non-Hispanic whites. Latinos have a poverty rate 

which is over twice as high as the Anglos in Los Angeles County, 

yet the life expectancy at birth for Latinos in Las Angeles is almost 

21⁄2 years higher than for whites. We should want to understand 

how this sort of an outcome can occur. 

In Figure 8 in my testimony, I use an analysis, or I present an 

analysis, done by the New York City Department of Health which 

shows life expectancy by ethnicity and by poverty statuses, neighborhoods. One of the fascinating results here, for Asian-Americans, 

the poverty status of neighborhoods makes practically no difference 

in life expectancy, and life expectancy for Asian-Americans in New 

York City is higher than for any other group. We should want to 

know how that can be. 

25 

Finally, Figures 11 and 12, I take estimates made by the Social 

Science Research Council in New York City for life expectancy by 

ethnicity by State across the United States, and I compare these 

with life expectancy as estimated by the U.S. Census Bureau for 

various OECD countries. 

You can see in Figure 11 that for Hispanic Americans taken by 

themselves, life expectancy at birth is higher than for any OECD 

country. The healthiest country in the world at this point is Japan. 

Latino life expectancy in America is higher than life expectancy in 

Japan. And the figures for Asian-Americans are just off the charts. 

If the United States was a nation of only Latinos and AsianAmericans, disadvantaged groups by these indicators I used, we 

would be the healthiest country on earth. 

A question for us, it seems to me, a critical question is: how do 

some disadvantaged groups achieve excellent, world-class health 

outcomes? If we answer that question, I think we can help to increase health for all Americans. 

Thank you. 

[The prepared statement of Mr. Eberstadt follows:] 

PREPARED STATEMENT OF NICHOLAS EBERSTADT, PH.D., MPA, M.SC. 

Mr. Chairman, distinguished Members, esteemed co-panelists and guests, in these 

august chambers, as in other policymaking circles in Washington and around the 

Nation, a policy syllogism is gaining currency and receiving increasingly respectful 

attention. The syllogism runs something like this: health progress is faltering in 

America today; faltering health progress is the consequence of social and economic 

disparities; therefore government must intervene to reduce disparities if health 

progress is to be revitalized. 

Influential as this syllogism has come to be nowadays, I submit that it is empirically flawed, and therefore requires serious qualification and re-examination. 

The problem with the syllogism lies not in its assertion that health progress in 

modern America is disappointing. For the Nation as a whole, the evidence to this 

effect is, unfortunately, overwhelming. 

Rather, the trouble lies with the proposition that social and economic disparities 

are the cause of America’s disappointing health performance today. 

To be clear: this is not to ignore the great corpus of data pointing to a widening 

of income differences and other economic differences in America over the past generation. Nor is it to suggest that it is not better to be affluent, educated, and wellinsured. Obviously it is: and not just for reasons bearing on health. 

Yet the perhaps curious fact of the matter is that real existing social and economic disparities are just not that good in predicting real existing health disparities 

in our real existing modern America. In fact, it is commonplace today for poorer, 

less-educated groups to enjoy substantially *better* health outcomes than those who 

would appear to enjoy distinctly greater socioeconomic advantages. The surprising— 

but also hopeful—fact is that it is possible for groups suffering what might be described as both social and economic disadvantage to achieve very good health outcomes in America today. And that is not just a technical, arcane, theoretical possibility: it is a main street reality, ratified by the survival profiles of millions upon 

millions of Americans today. 

We manifestly need to understand exactly how it is that so many Americans today 

manage to achieve good or excellent health outcomes with limited incomes, educational backgrounds, and other socioeconomic resources. But manifestly, the mental 

straitjacket that the ‘‘social disparities’’ mindset imposes on public health research 

is incapable of helping us in this critical task. 

The tables and graphs that accompany this written statement offer data and analysis that underscore, and expand upon, the summary points offered telegraphically 

in the preceding paragraphs. 

Let us begin with the question of America’s health record over the postwar era. 

There is really no question at this point as to the at-best mediocre results we as 

a society have garnered over the past half century and more. While our country has 

achieved continuing incremental improvements in overall health conditions (as reflected in the mirror of mortality), our progress has been decidedly slower than in 

26 

other affluent Western democracies—and thus our ranking in this roster has gradually but steadily declined. 

We can see this in Figures 1 and 2 of the attachment to this written statement. 

[See Figures 1 and 2] The graphics trace out the trends in years of combined male 

and female life expectancy at birth on the one hand, and infant mortality rates per 

thousand live births on the other hand, for the United States and 23 other nevercommunist members of the OECD (Organization for Economic Cooperation and Development), an association of aid-dispensing Western industrialized democracies. 

These estimates come from the Human Mortality Data base, a project undertaken 

by the University of California at Berkeley and the Max Planck Institute for Demographic Research in Germany—since experts in this network have carefully examined the underlying data from all these countries and offered their own corrections 

or reconstructions as warranted, we get an ‘‘apples to apples’’ comparison here. 

As can be seen in Figures 1 and 2, despite continuing progress in reducing mortality levels, America has gone from a more or less middling ranking in this pack 

of 24 countries shortly after the end of World War II (1950) to the very poorest 

ranking among these 24 countries today (circa 2010). Life expectancy at birth is now 

estimated by the Human Mortality Database researchers to be lower in the USA 

than in any of the other 23 comparators—and infant mortality conversely is placed 

highest in the USA for any country in this same group. Trend lines for the odds 

of surviving from birth to say age 65, or any other measure for the risk of premature mortality, would tell a roughly similar story for America’s health performance over the postwar era. 

What accounts for this long-term relative decline in U.S. health performance? 

Over the past half century, America has become an increasingly multiethnic society, and it has also seen the emergence of growing economic differences. (Admittedly, rising measured economic differences have also been characteristic of almost 

all other affluent Western democracies over these same decades—but measured income dispersion in the USA today appears to be greater than in almost all of the 

comparator countries in Figures 1 and 2). 

It is tempting to link these big changes in American society and economy with 

our disappointing health performance. This impulse, indeed, is at the heart of the 

current popularity of the ‘‘social disparities’’ paradigm, so widely utilized in public 

health research on America today. There is no gainsaying the general insight that 

more prosperous and better-educated people should be expected to have more favorable health outcomes than those who are less well-to-do. But as a practical matter, 

socioeconomic disparities do not seem to offer us all that much help in understanding the big health differentials we see in our society today. 

Table 1 makes the point. [See Table 1] It presents figures for America’s major ethnic groups on the one hand for major indices of social and economic disparity—poverty rates; proportions of the adult population without high school education; income 

distribution for families; percentages of persons without health insurance; percentages of adults with no health care visits over the previous 12 months—and on the 

other for age-standardized mortality. 

If the ‘‘social disparities’’ model has much predictive power in the modern American context, we would expect these major disparities to track with differential in 

mortality. We should bear this in mind when we examine the findings in Table 1. 

Consider what this table reveals for the ‘‘non-Hispanic White’’ (i.e., ‘‘Anglo’’) population in contemporary America (i.e., around the year 2010). By all indicators in this 

table—poverty, education, income distribution, access to health insurance, use of 

health services in the past 12 months—the ‘‘Anglo’’ community or population appears to be decidedly better off on average than Americans as a whole. But age 

standardized mortality for Anglos is no better than for the U.S.A. as a whole. Indeed, age standardized mortality is reportedly slightly *higher* for Anglos than for 

the Nation as a whole. 

Needless to say, if social and economic disparities were the dominant factor in determining health outcomes in the United States, the improbable correspondence between relative socioeconomic privilege and slightly less-than-average health results 

for Anglo America today would be unfathomable. But the situation is even more 

striking than this one comparison would suggest. 

Consider next the circumstances for our Asian minority (officially, Asian and Pacific Islanders). On all of the social and economic indicators in Table 1, the Asian 

population fares less favorably than the Anglos. Yet age-standardized mortality levels for our Asian-Pacific population are officially estimated to be over 40 percent 

below the national average. 

Finally, consider the situation for the Hispanic population in America today. By 

a number of measures, it would appear to be *the* most socioeconomically disadvantaged major ethnic group in America today. Nearly 40 percent of Hispanic American 

27 

adults, for example, have no high school degree (2009); over 30 percent of all have 

no health insurance (2010); and nearly 30 percent of Hispanic adults did not report 

even a single visit to get health care over the previous year (2010). Even so: the 

age-standardized mortality level for Hispanic Americans is estimated to be fully 25 

percent lower than the average for the Nation as a whole! 

Thus the striking paradox of health in modern America is this: minority groups 

reporting higher incidences of poverty and income inequality, lower educational attainment, less health insurance coverage, and greater likelihood of no treatment by 

medical professionals than our Anglo majority also report significantly lower mortality (and thus longer life expectancy) than our Anglos—indeed, significantly better 

mortality levels than for America as a whole. And this paradox is not new: as Figures 3 and 4 attest, for males and females alike, mortality rates for our Asian and 

Hispanic minorities have been superior to those of non-Hispanic Whites for many 

decades—in fact, for as long as such numbers have been compiled. Non-Hispanic 

Blacks or African-Americans are the only ethnic minority whose health profile appears to be poorer nowadays than our Anglos. 

The phenomenon of superior health performance by ostensibly disadvantaged minorities can be seen from sea to shining sea. Consider first Los Angeles County: 

with nearly 10 million inhabitants, the Nation’s most populous jurisdiction, fewer 

than 30 percent of whose residents are Anglos. [See Figure 5] According to the LA 

County Department of Public Health, total male and female life expectancy at birth 

for these non-Hispanic White residents in 2010 was actually a bit below the countywide average (80.8 years vs. 81.5 years). But the official poverty rate for the Anglo 

population in LA County is well below the countrywide average. On the other hand, 

Hispanics and Asians both suffered higher poverty rates than Anglos—the rate for 

Latinos was over twice as high as for non-Hispanic Whites—yet their life 

expectancies were also markedly higher. In 2010, the Latino edge in life expectancy 

over Anglos in LA County amounted to roughly 2.4 years; for Asians, the premium 

was fully 5 years. Is ‘‘your social and economic status’’ a ‘‘death sentence in America,’’ as the title of our hearing today avers? Evidently, not in Los Angeles. 

Now consider New York City, the Nation’s biggest urban jurisdiction. [See Figure 

6] As we all know, the ‘‘Hispanic’’ designation encompasses a wide variety of backgrounds. In terms of country or place of origin, the Latino population of New York 

City is quite different from Los Angeles County. No matter: according to the New 

York Department of Health, Hispanics still edge out Whites in life expectancy in 

New York City, and have been doing so for many years, even though the Hispanic 

population’s poverty rate in 2010 was over twice as high as the rate for Whites. 

If we look at age-standardized mortality in New York City, we see our national 

health paradox instantiated locally. [See Figure 7] Here again, mortality levels are 

lower for Hispanics and for Asians than for Whites, even though their official poverty rates are higher. It is true that mortality levels for New York’s Black population is dramatically higher than for its White population—and poverty rates for 

Blacks in New York were about twice as high as for non-Hispanic Whites in the 

period under consideration. But the Hispanic poverty rate in New York was very 

appreciably higher than the Black rate, even as the Hispanic age-adjusted mortality 

levels were fully one-third lower than Black levels. 

In and of itself, poverty just isn’t that good a predictor of health outcomes in New 

York City. That point is further emphasized in an analysis by the New York City 

Department of Health on life expectancy, ethnicity, and neighborhoods. [See Figure 

8] It is true that the very lowest life expectancy was recorded for Black New Yorkers 

who lived in the city’s poorest neighborhoods. It is also true that life expectancy generally tended to increase for city residents as the affluence of their neighborhood 

increased. So far, so good for the ‘‘social disparity’’ model. But the biggest differences 

in health outcome in New York City just can’t be predicted by this proxy of affluence 

or disadvantage. Note that life expectancy for African-Americans in the city’s most 

affluent neighborhoods was notably lower than for Hispanics in the city’s poorest 

neighborhoods. Note as well that there was no ‘‘poverty neighborhood’’ effect whatsoever for New York’s Asian population. Indeed: according to this analysis, the very 

healthiest group in New York City was Asians who lived in New York’s poorest 

neighborhoods. These people enjoyed life expectancies roughly 5 years higher than 

for Whites from the city’s wealthiest neighborhoods. 

Let us return to our international comparison of America’s health performance. 

The disappointing picture painted in Figure 1 turns out to be much more interesting, and somewhat more promising, when we disaggregate life expectancy by 

State and by ethnicity. We can do so with the aid of research by the ‘‘Measure of 

America’’ project from the Social Science Research Council (SSRC), which permits 

us to compare State-level life expectancy at birth by ethnicity with U.S. Census Bureau estimates for life expectancy at birth for the rest of the OECD. [See Figures 

28 

9–12] As we can see, America’s international health standing depends very much 

on which group and region we are talking about. 

For African-Americans, the story is pretty dispiriting—the nationwide average for 

life expectancy for American Blacks is lower than the life expectancy of all but three 

of the OECD’s 34 countries, and even the highest calculated State-level AfricanAmerican life expectancy (Rhode Island) is lower than 20 of the OECD’s countrylevel averages. 

For U.S. Whites, the situation looks better, but only to a degree. By these SSRC 

calculations, the nationwide life expectancy at birth for America’s Whites ranks 

below the life expectancy at birth of fully 20 OECD countries, as estimated by the 

U.S. Census Bureau. The dispersion of life expectancy by State for America’s Whites 

is noteworthy. Among U.S. Whites, life expectancy for the longest living region 

(Washington DC) is higher than for any country in the OECD—but life expectancy 

for the lowest region (West Virginia) is worse than for all but four OECD nations. 

When we place Hispanic America’s health in international perspective, the contrast is dramatic. To many viewers, the results are likely to be unexpected. By 

themselves, Hispanic Americans today are estimated to enjoy a life expectancy higher than for any country in the OECD—higher even than Japan, the world’s healthiest society by the yardstick of life expectancy. 

And America’s Asian population is almost off the chart. By the SSRC’s reckoning, 

Asian Americans nationwide can expect to live about 5 years longer than citizens 

of Japan; life expectancy for Asian Americans in their lowest-health State (Hawaii) 

would be a bit higher than life expectancy in Switzerland; and in at least six States. 

Asian-American life expectancy at birth nowadays is placed above 90 years. 

Viewed from this perspective, America’s health problem looks a little different 

from the conventional formulations. If the United States were a nation composed 

solely of its Hispanic and Asian Pacific minorities—populations, as we have seen, 

where conventionally described ‘‘social disparities’’ weigh heavier than on the Nation 

as a whole—we would be the healthiest country on earth. Our nationwide health 

problem is a problem within our African-American population—a group that suffers 

disproportionately from poverty and other conventional metrics of socioeconomic disadvantage—and our Anglo population—a group that suffers *less* from poverty and 

other conventional metric of socioeconomic disadvantage than the Nation as a 

whole. 

As should by now be apparent, health outcomes in modern America are a consequence of something beyond abstract social forces. Seeming victims of ‘‘social disparities’’ regularly achieve high levels of life expectancy—very often, levels better 

than those with seemingly greater social and economic advantages. If we are truly 

interested in improving our country’s public health conditions, we should be asking 

what is going *right* in these populations and these communities. Is it behavior? 

Lifestyles? Outlook and attitudes? Some combination of these things? We should 

desperately want to know. We will not—indeed cannot—learn the answers to this 

critically important question to our Nation’s well-being if we insist on attempting 

to protect the conclusion that social inequality is really what ails us. 

29 

Attachments—Tables and Figures 


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Senator SANDERS. Thank you very much. 

Senator Baldwin, did you want to introduce Dr. Kindig? 

STATEMENT OF SENATOR BALDWIN

Senator BALDWIN. I would be honored. Thank you, Mr. Chairman. 


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37 

I want to thank you and Ranking Member Burr for convening 

this hearing. We all know of your longstanding commitment to 

issues of income inequality, poverty, and health disparities. Too 

often, these issues are not discussed; they are swept under the rug. 

We know as a Nation, we have to do better to make sure that every 

American has a fair shake and a fair shot at success. Thank you, 

Mr. Chairman. 

You have invited a distinguished panel here today, including a 

star from my home State of Wisconsin. Dr. David Kindig is Emeritus Professor of Population Health Sciences and Emeritus Life 

Chancellor for Health Sciences at the University of Wisconsin 

Madison School of Medicine. He co-directs the Wisconsin site of the 

Robert Wood Johnson Health & Society Scholars Program. He also 

serves as editor for the Improving Population Health blog. 

Dr. Kindig served as senior advisor to Donna Shalala, Secretary 

of Health and Human Services, from 1993 to 1995. In 1996, he was 

elected to the Institute of Medicine National Academy of Sciences. 

He chaired the Institute of Medicine’s Committee on Health Literacy in 2002 to 2004, as well as Wisconsin Governor Jim Doyle’s 

Healthy Wisconsin Task force in 2006. In 2007, he received the 

Wisconsin Public Health Association’s Distinguished Service to 

Public Health Award. 

Dr. Kindig. 

STATEMENT OF DAVID A. KINDIG, M.D., Ph.D., EMERITUS PROFESSOR OF POPULATION HEALTH SCIENCES, UNIVERSITY 

OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH, 

MADISON, WI 

Dr. KINDIG. Thank you very much, Senator Sanders, Senator 

Warren, and Senator Baldwin for that really warm introduction. 

Great to see you here in this role. 

I thank you all for the opportunity to speak today about the social and economic factors that have caused many Americans to 

have shorter and less healthy lives than the generations that have 

gone before them. I have worked my whole career in what we now 

call population health, beginning as a pediatric resident in a poverty neighborhood in the South Bronx and serving as the first Medical Director of the National Health Service Corps in 1971. 

This hearing shines light on something that many people do not 

yet understand: that while healthcare is necessary for health, it is 

not the only, nor even the most, important factor in producing 

longer, healthier, and more productive lives. Health is produced by 

many factors including medical care and health behaviors, but 

equally importantly or more importantly, issues like income, education, the structure of our neighborhoods, as my colleagues have 

been showing. 

The bottom line is we will not improve our poor health performance unless we balance our financial and policy investment across 

this whole portfolio of factors. 

For many years, I ran the Population Health Institute at the 

University of Wisconsin School of Medicine and Public Health. 

With my colleagues, we created the County Health Rankings for 

use in Wisconsin prior to collaborating with the Robert Wood Johnson Foundation to take the rankings national. 

38 

An easy to use snapshot, the rankings compare counties on a 

range of factors, as I have mentioned, particularly including the social factors on employment and income. In fact, we weight those 

factors in the rankings model as 40 percent of what impacts our 

health outcomes. 

We initially did this for 6 years in Wisconsin for only our 72 

counties. I will never forget the first morning we released those 

first rankings. I got a call from a radio talk show in a rural Wisconsin town; I believe it was Platteville. The first question asked 

was, this is like 7:30 a.m., ‘‘Dr. Kindig, does this report mean that 

income levels in our county is as important as the number of persons with health insurance? ’’ I was surprised, but I could not have 

been more gratified to get that kind of a call to begin that program. 

I encourage each of you to take a look at the rankings in your 

State and see the factors which impact the health of those counties. 

The last several decades have shown a growing awareness of 

such a broad perspective, work like Lisa’s and Steve’s and others. 

Currently, I am co-chair of a new Institute of Medicine Roundtable 

on Population Health Improvement, just started 6 months ago. The 

vision of that roundtable starts, outcome such as improved life expectancy, quality of life, and health for all are shaped by interdependent, social, economic behavior factors and will require robust 

national and community-based actions and dependable resources to 

achieve it. 

In my testimony, I listed several studies that we have done on 

this matter, I’ll highlight two orally. One showed a fourfold variation in county death rates substantially influenced by medianfamily income level. An $8,900 increase in median-family income 

was associated with an 18 percent reduction in death rates in lowincome counties and 12 percent in high-income counties. 

Another study that the Chairman referred to, which is the map 

before you, showed this shocking, actually, increase in female mortality rates across the United States. The most important factors 

associated with this were college education, smoking, and median 

household income. 

We know now that much more than healthcare is needed. Even 

though, of course, everyone needs access to affordable, quality care. 

Evidence for investments in efforts like early childhood education 

and many prevention programs, there is good, strong evidence for 

that, and that is beginning to result in new investments in many 

American communities. 

But in a time of limited resources, we still need more efforts from 

private foundations and the Federal Government to much more aggressively fund the kind of studies that will help us to determine 

the most cost-effective investment and policy choices across these 

multiple determinants for a healthier future so we can make the 

right balance of investments. 

We do know enough to act now, however. I am not just advocating research. As a former pediatrician, it just pains me that 

many children born today in poverty will have shorter and 

unhealthier lives determined in the next few years, by the time 

they get to middle school. That will impact those maps as we go 

forward. 

39 

I have been looking at these maps for my entire career and I am, 

frankly, very tired of it. At a time when the important issue of 

medical care access and cost is front page news every day, I commend this committee for bringing attention to the other determinants of health, which are at least as important in changing the 

color of these maps. 

It is time for these maps to change. 

Thank you very much. 

[The prepared statement of Dr. Kindig follows:] 

PREPARED STATEMENT OF DAVID A. KINDIG, M.D., PH.D. 

Thank you Chairman Sanders and Ranking Member Burr for the opportunity to 

speak today about the social and economic factors that have caused many Americans to have shorter and less healthy lives than the generations that have gone before them. 

My name is David Kindig, and I am Emeritus Professor of Population Health 

Sciences at the University of Wisconsin School of Medicine and Public Health. I 

have worked my whole career in what we now call population health, beginning as 

a pediatric resident in an Office of Economic Opportunity Neighborhood Health Center in the South Bronx and serving as the first Medical Director of the National 

Health Service Corps in 1971. 

This hearing shines needed light on something that many citizens and policymakers don’t yet understand . . . that while health CARE is necessary for health, 

it is not the only or even the most important factor in producing longer life and lives 

of high quality and productivity. As my colleagues have already pointed out, modern 

epidemiology and social science have established that health is produced by many 

factors including medical care and health behaviors and, importantly, components 

of the social and physical environment in which we live in like income, education, 

social support, and the structure of our neighborhoods. The bottom line is that we 

will not improve our poor performance unless we balance our financial and policy 

investments across this whole portfolio of factors. 

For many years I ran the Population Health Institute at the University of Wisconsin School of Medicine and Public Health, and with my colleagues created the 

initial County Health Rankings www.countyhealthrankings.org. An easy-to-use snapshot, the rankings look at the overall health of nearly every county in all States. 

They compare counties on a range of factors that influence health such as tobacco 

use, physical inactivity, and access to health care, and more importantly, social and 

economic factors, including education, employment and income. In fact, these latter 

factors are assigned the largest weight at 40 percent. (www.countyhealthrankings 

.org/our-approach). 

We initially did this for 7 years for only the 72 Wisconsin counties. I will never 

forget the morning of the first Wisconsin release, I got a call from an early morning 

radio talk show in rural Wisconsin and the first question asked was ‘‘Dr. Kindig, 

does this report mean that the income level in our county is as important as the 

number of persons with health insurance?’’ I could not have dreamed of a better and 

more sophisticated question to begin this program. I answered that this was certainly the case although we don’t know for sure the exact balance in every county 

since all places vary in both their health outcomes and the factors producing those 

outcomes. Today this same model is used all across the country in the national 

County Health Rankings and Roadmaps program, and many communities are using 

it to prioritize health needs and solutions across their community. In early 2013, 

six communities were awarded the initial RWJF Roadmaps to Health Prize; to be 

eligible they had to show excellence in all the determinants including social and economic factors. The initial six Prizes were awarded to two communities in Massachusetts and one each in California, Louisiana, Michigan, and Minnesota. (http:// 

www.countyhealthrankings.org/roadmaps/prize/about-prize). 

As my colleagues here have indicated, the last several decades have shown a 

growing awareness of such a broad perspective. Currently, I am co-chair of a new 

Institute of Medicine Roundtable on Population Health Improvement, whose vision 

states in part, 

‘‘Outcomes such as improved life expectancy, quality of life, and health for all 

are shaped by interdependent social, economic, environmental, genetic, behavioral, and health care factors, and will require robust national and communitybased actions and dependable resources to achieve it . . . the roundtable will 

therefore facilitate sustainable collaborative action by a community of scienceVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
40 

informed leaders in public health, health care, business, education and early 

childhood development, housing, agriculture, transportation, economic development and non-profit and faith-based organization.’’ 

I will briefly mention a few of the studies my colleagues and I have conducted 

on this topic. The first of two I did with my graduate student Erika Cheng in which 

we showed a fourfold variation in county death rates substantially influenced by median-family income level. 

An $8,900 increase in median-family income was associated with an 18 percent 

reduction in death rates in low-income counties and 12 percent in high-income counties. 

In the second study, shown on the map before you, we examined the change in 

mortality rates across U.S. counties over the past decade, and showed surprisingly 

that mortality rates for females had actually worsened in 42 percent of counties, 

those shown in the shaded area, primarily in the south and west regions. 


85792-17.eps
41 

We found several factors associated with this worsening, the most important 

being college education, smoking, and median-household income. In this study no 

medical care factors such as percent uninsured or number of primary care physicians were associated with this worsening over time. 

We also examined, ‘‘How Healthy Could a State Be?’’, in which we modeled how 

State mortality rates could improve if they each had the highest level of all the determinants that any State had already achieved. 

We found that even the healthiest State, New Hampshire, could improve mortality by 24 percent and the least healthy, West Virginia by 46 percent. The factors 

most associated with this improvement were reducing smoking rates, increasing insurance, increasing high school and college graduation rates, increasing medianfamily income, and increasing employment. 

So we know that much more than health care is needed, even though of course, 

everyone needs access to affordable quality care. Evidence for investments in efforts 

like early childhood education is strong, resulting in such new investments in many 


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42 

communities. An Institute of Medicine committee on Health Literacy that I chaired 

(A Prescription to End Confusion) found that 40 percent of American adults do not 

have adequate literacy skills to effectively navigate the health care system. But in 

a time of limited resources we do not know enough to guide exact choices of the 

most cost-effective investment balance across all determinants in a given community. This is why my colleague, John Mullahy, and I published a commentary in 

JAMA titled, ‘‘Comparative Effectiveness of What: Evaluation Strategies for Improving Population Health’’ (2010, 304 (8):901–2) in which we argued that now that we 

are realizing that social factors play such an important role in health outcomes, we 

need private foundations and the Federal Government to much more aggressively 

fund the kind of studies beyond medical care alone that will help us make the best 

investment and policy choices across the social determinants for a healthier future. 

But we know enough to act now. Many children born in poverty will have shorter 

and unhealthier lives determined by the time they get to middle school. I have been 

looking at these maps for my entire career and am frankly very tired of it. At a 

time when the important issue of medical care access and cost is front page news 

every day, I commend this committee for bringing attention to the other determinants of health which are at least as important in changing the color of these 

maps. 

Thank you for the invitation to appear before you today to discuss these important issues. I look forward to your questions. 

Senator SANDERS. Dr. Kindig, thank you very much. 

Our next panelist is Sabrina Shrader, who grew up in McDowell 

County, WV, and that is a county in our country with one of the 

lowest life expectancies. I believe it is the lowest for men, and the 

second lowest for women. 

Ms. Shrader tells us that she is one among millions who are 

struggling to make ends meet in our country. She now resides in 

Athens, WV where she is a master of school work student and program assistant for the Upward Bound program at Concord University. 

Ms. Shrader, thanks so much for being with us. 

STATEMENT OF SABRINA SHRADER, ATHENS, WV 

Ms. SHRADER. Thank you, Senator Sanders, Senator Baldwin, 

and Senator Warren. 

My name is Sabrina Shrader, and I am from a hollow in West 

Virginia called Twin Branch where we made a good neighborhood 

and community. Twin Branch is in McDowell County. It is one of 

the poorest counties in one of the poorest States of the country. 

Because of inadequate healthcare, lack of transportation, and 

lack of resources, I was born into a family that was afflicted by domestic violence, child abuse, and mental illnesses. These circumstances do not cause poverty; they are caused by poverty. My 

parents were not perfect, but they taught me to do my best, treat 

people how I wanted to be treated, and to pray. 

Influenced by poverty, their chances for success are often swayed 

by drug abuse, poor healthcare, limited access to healthy food 

choices, lifestyle habits such as smoking cigarettes, and little interstate access. 

Some say poverty is a death sentence. Frankly, I do not know 

how many times I have been given the death sentence. Even before 

I was born, doctors were questioning whether or not my mom 

should have me because she was 16-years-old and her future and 

mine looked bleak. The doctors did not even think I was alive and 

they told her she would die if she chose to have me. I was born 

3 months early and I was born without fingernails, eyelashes, and 

hair. 

43 

When I was in eleventh grade, my mom and I got into a terrible 

car accident on our way to the bus stop. I had made straight A’s 

for most of my life. The car wreck left me, as doctors said repeatedly, mentally challenged and paralyzed. I learned to walk and talk 

again, and I bounced back with resilience and I make good grades 

once again. 

Then I got to college, and I got meningitis, and I was given a 

death sentence once again. That time, I literally waited to die in 

the hospital. Fortunately, I survived. I went back to school, and I 

tried my hardest to learn, and here I am in front of you all today 

still wrestling with residual illnesses. 

I have seen many die before their time. I have had family members, friends, and classmates all die young. The deaths started a 

couple of days after I was born, with my mom’s favorite aunt dying. 

Later, one of my best friends died from a drug overdose. This past 

year, both of my stepsisters died. I could go on and on about all 

the young people I have seen die in West Virginia. 

A strong correlation between poverty and life expectancy exists. 

While many are born into poverty every day, poverty is not a 

child’s fault nor is it a family’s. No one asks for a life who is born 

into poverty, ask for a life that is encompassed with suffering for 

everything you need to live for every day, but nowadays, we seem 

more interested in taking things away from these kids instead of 

giving them a fair shot. 

Today, I am in the advanced standing master of social work program at Concord University, and I am the program assistant for 

the Upward Bound program there. This program gave me hope 

when I was in the sixth grade of one day being able to go to college. 

If it had not been for the program, I may not even know what a 

college campus look like, let alone even know that I could work at 

one. 

I am the first person in my family to not only graduate high 

school, but I am also the first to get a bachelor’s degree. If it had 

not been for TRIO programs like Upward Bound and student support services, I do not know where I would be today. TRIO programs help vulnerable kids who are labeled at-risk survive and 

gives them hope to follow their dreams. 

There are two Upward Bound programs at Concord University 

and they serve 150 high school students from five high-need counties in West Virginia. Sequestration cut our budget 5.23 percent 

and that means we will have to turn our backs on some needy kids, 

and we face additional budget cuts. 

Programs like Upward Bound and student support services make 

it a little easier to try harder and keep a positive attitude when 

times are tough and hope is rare. I watched my classmates who did 

not have the TRIO program and they ended up dropping out of 

school or using drugs. Some have committed suicide. Life should 

not end this way. 

TRIO programs make a huge difference for the kids living in poverty-stricken areas. High school graduation rates are near 100 percent and postsecondary education rates are 70 percent for povertystricken students enrolled in TRIO programs. TRIO programs save 

lives. 

44 

People living in poverty do not have as good of odds of living a 

long, happy, healthy life when compared to people who can easily 

meet their basic needs such as food, clothing, and shelter every 

day. 

I am not a success story. I did not pull myself up by my bootstraps. I am proof that we live in a country that even if you work 

hard and even if you do everything that you are supposed to do, 

you still may not have enough to make ends meet. 

I am still struggling to this day, but I am not struggling alone. 

I am also a leader with the Our Children, Our Future campaign. 

Our goal is to end child poverty in West Virginia, and this last 

year, we already helped win six statewide policy victories, from 

Medicaid extension to prison reform to expanding school breakfast 

programs. For the first part of my life, most people would not even 

listen to me, but this campaign has listened and helped me organize in my community to make a difference. Now I am showing everyone I know so that everyone else knows they can make a difference too. 

Thank you for your time and for listening. God bless you. 

[The prepared statement of Ms. Shrader follows:] 

PREPARED STATEMENT OF SABRINA SHRADER

My name is Sabrina Shrader and I am one among millions who are struggling 

to make ends meet in America. Unfortunately, it had been very difficult to succeed 

in the type of environment I have been given. Because of inadequate healthcare, 

lack of transportation, and lack of resources, I was born into a family that was afflicted by domestic violence, child abuse, and mental illness. My parents weren’t 

perfect but they taught me to do my best, treat people how I want to be treated, 

and to pray. 

I am from a hollow in West Virginia called Twin Branch. I grew up in McDowell 

County, one of the poorest counties, in one of the poorest States of the country. Due 

to conditions influenced by poverty, decreased chances for success are often swayed 

by drug abuse, poor healthcare, limited access to healthy food choices, unhealthy 

lifestyle habits such as smoking cigarettes and little interstate access. 

Some say poverty is a death sentence. Frankly, I don’t know how many times I 

have been given that death sentence. Even before I was born, doctors were questioning whether or not my mom should have me because she was 16 years old and 

her future and mine looked bleak. The doctors didn’t even think I was alive and 

they told her she would die if she chose to have me. I was born 3 months early and 

was born without fingernails, eye lashes, and hair. 

Another time I was given a not-so-positive prognosis was on a snowy day. When 

I was in the 11th grade, my mom and I got into a terrible car accident on our way 

to the bus stop. I had perfect attendance and had made almost straight A’s for most 

of my life. The car wreck left me as doctors said repeatedly ‘‘mentally challenged 

and paralyzed.’’ I learned to walk and talk again and I bounced back with resiliency 

and started to make good grades again. I made it to college and there I got meningitis and was given a death sentence once again. I literally waited to die that time 

I was in the hospital. Fortunately, I went back to school and tried my hardest to 

learn and here I am in front of you all today. 

Furthermore, I have seen many die before their time. I’ve had family members, 

friends, and classmates all die young. The deaths started a couple of days after I 

was born with my mom’s favorite aunt dying and another one of her favorite aunt’s 

dying a couple months after that. This past year, both of my stepsisters have died. 

One was in a car accident and had water on her brain from drowning in the river. 

She like me had learned to walk and talk again but after getting pneumonia repeatedly she died in the hospital. The other didn’t go to the hospital when she needed 

to for not wanting to incur additional medical bills and she died from a brain hemorrhage. 

A strong correlation between poverty and life expectancy exists. While many children are born into poverty every day, poverty is not a family’s fault and it is not 

a child’s fault. No one who is born into poverty asks for a life that is encompassed 

with suffering for everything you need to live for every day. But nowadays we seem 

45 

more interested in taking things away from these kids, instead of giving them a fair 

shot. 

Today, I am in the Advanced Standing Master of Social Work program at Concord 

University and I am the program assistant for the Upward Bound program at Concord too. This program gave me hope when I was in the 6th grade of one day being 

able to go to college. If it hadn’t been for the program, I may not even know what 

a college campus looks like. I am the first person in my family to not only graduate 

high school but to also get a bachelor’s degree. If it hadn’t been for TRIO programs 

like Upward Bound and Student Support Services, I don’t know where I would be 

today. 

TRIO programs help vulnerable kids survive and gives them hope to follow their 

dreams. There are two Upward Bound programs at Concord University and they 

serve 150 high school students from five high-need counties in West Virginia. Sequestration cut our budget 5.23 percent and TRIO programs face additional budget 

cuts thus causing fewer children to be helped. Programs like Upward Bound and 

Student Support Services make it a little easier to try harder and keep a positive 

attitude when times are tough and hope is rare. I have seen other people who are 

like me not be in TRIO programs and have suffered worse consequences such as 

being compelled to use drugs and some have committed suicide. 

TRIO programs make a huge difference for the students living in poverty stricken 

areas. High school graduation rates are near 100 percent and postsecondary education rates are 70 percent for poverty students enrolled in TRIO programs. TRIO 

programs save lives. People living in poverty do not have as good of odds of living 

a long happy healthy life when compared to people who can easily meet their basic 

needs such as food, clothing, and shelter every day. 

Please don’t misunderstand me when I say that I am not a success story. I am 

still struggling but I am not struggling alone. I am also a leader with the Our Children, Our Future Campaign. Our goal is to end child poverty in West Virginia. For 

the first part of my life, most people wouldn’t even listen to me. But this campaign 

has listened and helped me organize in my community to make a difference. Now 

I am telling everyone I know. I am talking with my family, my church, my workplace, and in my neighborhood so that everyone else knows they can make a difference too. Thank you for your time and for listening. God Bless You. 

Senator SANDERS. Well, thank you very much, Ms. Shrader, for 

your very powerful testimony. 

Our next witness is Dr. Michael Reisch, who is the Daniel 

Thursz Distinguished Professor of Social Justice at the University 

of Maryland School of Social Work in Baltimore. He has held faculty administrative positions at four other major universities and 

has played a leadership role in national and State advocacy, professional and social change organizations that focus on the needs of 

low-income children and families. 

Dr. Reisch, thanks so much for being with us. 

STATEMENT OF MICHAEL REISCH, Ph.D., MSW, DANIEL 

THURSZ DISTINGUISHED PROFESSOR OF SOCIAL JUSTICE, 

UNIVERSITY OF MARYLAND SCHOOL OF SOCIAL WORK, BALTIMORE, MD 

Mr. REISCH. Good morning, Senator Sanders, Baldwin, Warren, 

and Murphy. 

Thank you for the opportunity to participate in this panel. 

I know the effects of poverty, both personally and professionally. 

I grew up in New York City in public housing. My parents’ families 

were on Home Relief during the Great Depression. As a teenager, 

I was in a gang before being rescued by social workers at the local 

Y. Sometimes, you get dealt the right cards in life. Sadly, most people who live in poverty do not. 

Poverty is not merely a statistic, although we often treat it in abstract terms. For tens of millions of Americans, it is a persistent 

barrier to full participation in our society: economically, politically, 

46 

and socially. Of greater significance, poverty is also a thief. It stills 

years of life from its victims. 

Americans in the top 5 percent of income distribution live about 

9 years longer than those in the bottom 10 percent. Almost 50 million Americans, nearly 16 percent of the Nation, now live below the 

official poverty line; the highest poverty rate in a generation. The 

majority of people who are poor are children and youth, the elderly 

and individuals with disabilities. More than 20 million Americans 

experience deep poverty; they live below 50 percent of the official 

poverty line and 4 million Americans, half of them children, try to 

survive on $2 a day. It is estimated that half of all adults in the 

United States today are at economic risk in terms of their levels 

of literacy, education, and healthcare. 

But poverty is not merely a snapshot. Over 20 percent of poor individuals remain poor for a year or more. They have a 1-in–3 

chance of escaping poverty in a given year and the odds are much 

lower for African-Americans, Latinos, and female-headed households. Roughly half of those who escape poverty become poor again 

within 5 years. 

This duration of poverty spells is compounded by the widespread 

experience of poverty among Americans. Nearly 60 percent of the 

population and 91 percent of African-Americans experience an episode of poverty during their lifetime of 1 year or more, and over 

three-quarters of the population experiences at least a year of nearpoverty. The impact of cycling in and out of poverty has a profound 

effect on people’s health and longevity and on the stability of American communities. 

Children constitute the demographic cohort most likely to be 

poor. Nationally, 22 percent of children under the age of 18 and 

over one-fourth of children under the age of 5 are in poverty. 

Among African-American children, the figure is 36 percent. They 

are more likely to suffer from health ailments such as lead poisoning, asthma, and anemia. 

In addition, children growing up in low-income neighborhoods 

are much more likely to encounter a variety of environmental 

health and social hazards, such as elevated exposure to lead and 

toxic pollutants, crime and violence, dropping out of school, higher 

arrest rates, increased risk of substance abuse, and greater exposure to sexually transmitted diseases. These children are also less 

likely to finish high school and go to college, and more likely to become involved with the criminal justice system and develop chronic 

illnesses. They are, in effect, permanently trapped in the vise of 

poverty with all its deleterious effects on health and life expectancy. 

Hunger is perhaps the most visible and painful symptom of poverty. Today, over 50 million people, nearly 1 out of every 6 Americans experiences what is euphemistically called ‘‘food insufficiency.’’ 

Nearly 17 million people endure a very low food security and regularly run out of food several days each month. Here in the Nation’s 

Capital, nearly 31 percent of all children live in households without 

consistent access to food; the highest rate in the Nation. 

Hunger, particularly in the first 3 years of life, contribute significantly to a wide range of health problems, lowers the psychological 

development, greater prevalence of learning disabilities, and lower 

47 

academic achievement. The effects are similar among adults including women, and pregnant women, and the elderly. 

Let me illustrate by some data from two neighborhoods in Baltimore that are just 21⁄2 miles apart. The difference in life expectancy between those neighborhoods is almost 20 years regardless of 

race. In another neighborhood, Upton Druid Heights which is primarily African-American, life expectancy is 30 years less than that 

of Roland Park, which is primarily white. 

If just 5 percent more people in Baltimore attended some college 

and 5 percent more had incomes higher than twice the Federal poverty line, we could save, each year, 247 lives, prevent 27,000 cases 

of diabetes, and eliminate $202 million in diabetes costs every year. 

The impact of poverty on health and life expectancy of millions 

of Americans illustrates the growing importance of our fraying social safety net. Two years ago, these programs lifted 40 million people out of poverty including 9 million children. They lowered our 

official poverty rate by almost 14 percent. They are also fiscally 

prudent. Each 1 percent increase in child poverty costs us approximately $28 billion a year and the total costs associated with childhood poverty alone total almost one-half a trillion dollars per year, 

or the equivalent of nearly 4 percent of GDP. 

Given the long term effects of poverty on people’s life expectancy, 

and the damage it does to the well-being of our communities and 

our Nation, this is a time to expand, and not reduce, these essential life-giving programs. 

Thank you very much for your attention. 

[The prepared statement of Mr. Reisch follows:] 

PREPARED STATEMENT OF MICHAEL REISCH, PH.D., MSW 

Good morning, Senators Sanders and Burr. Thank you for the opportunity to participate in this panel. I know the effects of poverty both personally and professionally. I grew up in New York City in public housing. My grandparents were immigrants, and my parents’ families were on relief during the Great Depression. As 

a teenager, I was in a gang before being rescued by social workers at the local Y. 

I was fortunate. Sometimes, you get dealt the right cards in life. Sadly, most people 

who live in poverty do not. 

From my research and professional practice experience, I have learned that poverty is not merely a statistic, a snapshot of individual and family well-being, although we often treat it in such abstract terms. For tens of millions of Americans, 

it is a persistent barrier to full participation in our society, economically, politically 

and socially. Of greater significance, poverty is also a thief. Poverty not only diminishes a person’s life chances, it steals years from one’s life itself. 

POVERTY IN THE UNITED STATES

In 2012, using new methods of calculation, the U.S. Census Bureau found that 

almost 50 million people in the United States were poor, 3 million more than in 

2010. This is the largest number of people in poverty since the United States began 

to measure poverty and the highest poverty rate in a generation (U.S. Bureau of 

the Census, 2012a). Nearly 16 percent of the U.S. population now lives below the 

official poverty line, which in 2013 is slightly above $23,000/year for a family of four. 

The majority of people who are poor are the most vulnerable members of our society. Thirty-five percent are under the age of 18. Eight percent are over the age of 

65; 9 percent are between the ages of 18 and 64 and suffer from some type of disability (U.S. Census Bureau, 2012a). Over one-quarter of African-Americans and 

Latinos now live below the poverty line; since 1980, they have been 21⁄2–3 times 

more likely to be poor than white, non-Hispanic Americans. Over 1⁄3 of AfricanAmerican children and all young families are poor. Women, particularly elderly 

women and single parents, are also more likely to be poor at every educational level. 

Poverty among unmarried female-headed households is nearly 40 percent—the highVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
48 

est rate of poverty for female-headed households among 22 industrialized nations, 

about three times higher than average (U.S. Bureau of the Census, 2012b). 

Poverty in the United States is no longer confined to depressed inner city neighborhoods or isolated rural areas. Since 2010, the number and percentage of people 

in poverty increased in 17 States, particularly in the South and West, and in suburban areas as well. It is estimated that half of all adults in the United States today 

are at economic risk in terms of their levels of literacy, education, and health care. 

Poverty is not only more extensive, it is also deeper and more persistent. More 

than 20 million Americans, including nearly 12 percent of African-Americans and 

over 10 percent of Latinos experience ‘‘deep poverty,’’ defined as below 50 percent 

of the official Federal poverty line (U.S. Bureau of the Census, 2012b; Acs & Nichols, 2010; Buss, 2010). Almost half of the families living in poverty actually live 

below one-half of the official poverty line (U.S. Census Bureau, 2012a). Four million 

Americans, half of them children, live in extreme poverty and try to survive on $2/ 

day. 

Over 20 percent of poor individuals are chronically poor (i.e., remain poor for a 

year or more). African-Americans, Latinos, and female-headed households are over 

five times more likely than whites to experience chronic poverty (U.S. Census Bureau, 2011). On average, individuals in poverty have a one in three chance of escaping poverty in a given year, although this probability is much lower among AfricanAmericans, Latinos, female-headed households, and larger families. Roughly half of 

those who escape poverty become poor again within 5 years. Race, household status, 

and level of education are the key factors determining whether an individual can 

permanently escape poverty. 

The duration of poverty spells is compounded by the widespread experience of 

poverty among Americans. Nearly 60 percent of the population experiences an episode of poverty during their lifetime of 1 year or more between the ages of 20–75, 

and over 3⁄4 of the population experiences at least a year of near poverty. Even more 

striking is that 91 percent of African-Americans will experience poverty at some 

point in their lives (Rank, 2004). 

Many analysts believe that the poverty rate is underestimated by half because it 

excludes homeless persons, people who are incarcerated, and people ‘‘doubled up’’ 

and living with family members. It also fails to consider the high cost of living in 

many metropolitan areas. Three-fourths of Americans have incomes under $50,000/ 

year, considerably below what it takes to live a minimally decent life in major cities. 

The official poverty line has not been adjusted to increases in real income and 

changes in living standards since it was formulated nearly 50 years ago. If the poverty line was raised by 10 percent, about one-third of the U.S. population (100 million persons) would be poor (Buss, 2010). 

Given our knowledge about the long-term effects of poverty on health, psychological development, and educational attainment, these figures indicate the extent 

to which large numbers of the U.S. population, particularly in communities of color 

or immigrant communities, are at risk of a wide range of health, mental health, and 

social problems (Monea & Sawhill, 2010; Edelman, Golden, & Holzer, 2010; Pavetti 

& Rosenbaum, 2010; Lim, Coulton, & Lalich, 2009; Fertig & Reingold, 2008; 

Auerbach & Kellermann, 2011; Galea, Tracy, Hoggatt, DiMaggio, & Karpati, 2011). 

The impact of cycling in and out of poverty has a profound impact on people’s health 

and longevity and on stability of American communities (Acs & Nichols, 2010; 

Pavetti & Rosenbaum, 2010; Turner, Oliff, & Williams, 2010). 

POVERTY AMONG CHILDREN

Children constitute the demographic cohort most likely to be poor, a phenomenon 

unprecedented in industrialized nations. Nationally, nearly 22 percent of children 

under the age of 18 and over 1⁄4th of children under the age of 5 were in poverty. 

Among African-American children, the figure was 36 percent. Children who experience extended periods of poverty are less likely to finish high school and go to college. They are more likely to become involved with the criminal justice system and 

to develop chronic illnesses. The life course risk of poverty appears to have increased during the past several decades especially for individuals in their 20s, 30s, 

and 40s (Sandoval, Rank, and Hirschl, 2009; Alesina & Glaeser, 2004; Gornick & 

Jantti, 2012; Smeeding, 2005) 

Children in poverty are nearly three times as likely to have fair or poor health 

and over twice as likely to have parents who report symptoms of poor mental health 

(Loprest & Zedlewski, 2006; Case, Fertig, & Paxson, 2005). Children in poverty are 

more likely to suffer from various health ailments, such as lead poisoning, asthma, 

and injury from accidents and violence (Aber, et al., 1997). Poverty and poor nutrition produce a wide range of health and behavioral problems, slower psychological 

49 

development, greater frequency of learning disabilities, and lower academic achievement. Nonwhite children in particular are routinely exposed to high levels of neighborhood poverty when growing up compared to their white counterparts (Drake & 

Rank, 2009). Exposure to such levels of poverty can have a profound impact upon 

one’s life chances and life expectancy. 

For example, children growing up in neighborhoods marked by high poverty are 

much more likely to encounter a variety of environmental health and social hazards. 

These include elevated exposure to toxic pollutants, greater likelihood of being victimized by crime and violence, dropping out of school, higher arrest rates, increased 

risk of substance abuse, and greater exposure to sexually transmitted diseases 

(Evans, 2004). All of these can detrimentally affect a child’s health, which in turn, 

can have a profound impact upon that child’s health and economic well-being as an 

adult. 

In addition, the infant mortality rate in the United States is higher than in some 

developing nations and the U.S. life expectancy ranks near the bottom among comparable industrialized countries. While in neighboring Mexico 90 percent of all children under five are immunized against childhood diseases, in some U.S. cities the 

rate is below 50 percent (Children’s Defense Fund, 2006). As a result of persistent 

health disparities, Americans in the top 5 percent of the income distribution can expect to live approximately 9 years longer than those in the bottom 10 percent 

(Jencks, 2002). In two neighborhoods in Baltimore, just 2.5 miles apart, the difference in life expectancy is almost 20 years regardless of race (LaVeist, et al., 

2010). 

Children born into low-income families also have far less opportunity to be 

upwardly mobile than in the past. As educational attainment and job skills become 

increasingly important determinants of economic success in the global market, children from lower SES backgrounds face mounting obstacles due to the inadequacy 

of the schools most of them attend (Economic Policy Institute, 2012; Collins & 

Mayer, 2010; Allard, 2009; Wacquant, 2009; Blank & Kovak, 2008). Yet, in order 

to compete effectively for economic opportunities today, the quality and the quantity 

of their education are critical. On both counts, poverty and lower income status 

stunt the educational process. Those growing up in poor households are likely to live 

in lower income areas which have fewer financial resources to spend on their school 

systems. This results in a significant reduction in the quality of education that students who are poor receive. 

Racial and class gaps in education, particularly in regard to workforce preparation 

at the secondary school level, create especially acute problems for African-American, 

Latino, and American Indian youth. These problems are even more serious for the 

children of recent immigrants, documented or undocumented, and for children in 

single family female-headed households (Bureau of Labor Statistics, 2010; Collins & 

Mayer, 2010; Wacquant, 2009; Soss, Fording, & Schram, 2011; Braveman, et al,, 

2011). They are, in effect, trapped in the vise of poverty with all of its deleterious 

health effects. 

Finally, child poverty is also a drain on the Nation’s economy. Six years ago, a 

study (Holzer, Schanzenbach, Duncan, & Ludwig, 2007) concluded that ‘‘the costs 

to the United States associated with childhood poverty total about $500 billion per 

year, or the equivalent of nearly 4 percent of GDP’’ (p. 1). Each 1 percent increase 

in child poverty costs the Nation approximately $28 billion/year. 

POVERTY AND HUNGER

Hunger is, perhaps, the most visible and painful symptom of poverty. Today, over 

50 million people in the United States—nearly one out of every six Americans—experiences what is euphemistically called ‘‘food insufficiency.’’ This number has nearly doubled since 2000. Nearly 17 million people endure ‘‘very low food security.’’ 

Their food intake is below levels considered adequate by nutritional experts. They 

regularly run out of food several days each month. 

Poverty and hunger in the United States are not confined to any geographic region or segment of the population. Although less visible, they exist in startling and 

increasing numbers in suburbs and rural areas. About 1⁄8th of suburban households 

and over 1⁄7th of rural households experience food insecurity; almost 5 percent experience very low food security. Nearly half of all Americans who receive food assistance live in these communities. The problem is particularly severe in southern and 

western States. 

About one-third of the people who are hungry in America are children and over 

22 percent of all children nationally live in households that experience hunger. In 

36 of the 50 States, over 20 percent of children are hungry. Over 25 percent of African-American and Latino households experience food insecurity. Here, in the NaVerDate Nov 24 2008 13:10 Nov 08, 2016 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6621 S:\DOCS\22267.TXT DENISE
50 

tion’s capital, nearly 31 percent of all children live in households without consistent 

access to food—the highest rate in the Nation (Cohen, Mabli, Potter, & Zhao, 2011). 

It has been clearly established that hunger, particularly in the first 3 years of life, 

has dramatic implications for children’s future physical and mental health, academic achievement, and economic productivity. Children’s hunger contributes significantly to a wide range of health problems, to slower psychological development, 

greater prevalence of learning disabilities, and lower academic achievement. Children growing up in food insecure households are more likely to require hospitalization, have more frequent instances of oral health problems, and may be at higher 

risk for conditions such as anemia and asthma. They may also be at higher risk 

for behavioral issues, such as school truancy and tardiness, and more likely to experience a range of behavioral problems including hyperactivity, aggression, anxiety, 

mood swings, and bullying. Children who are chronically hungry often lag behind 

in academic development, with clear implications for their ultimate life chances. 

The problem of hunger is slightly less severe, but still quite serious, for working 

adults and the elderly population in the United States. Among adults, food insecurity correlates strong with a variety of negative physical health outcomes, such as 

diabetes, hypertension, and various cardiovascular risk factors. There is also a demonstrated relationship between hunger and higher levels of aggression and anxiety. 

Pregnant women who experience food insecurity are at risk of premature births, 

low-birth-weight babies, and other birth complications. Women who experience hunger may be at greater risk of major depression and other mental health problems. 

Food insecurity among the children of mothers who are food insecure has also been 

linked with delayed development, poorer parental attachment, and learning difficulties during the first 2 years of life (Gundersen, Waxman, Engelhard, Del Vecchio, 

Satoh, & Lopez-Betanzos, 2012). 

Over 8 percent of households with one or more elderly Americans experienced 

hunger in 2011, the last year for which complete data are available. Seniors are 

more likely to be food insecure if they live in a southern State, are younger, live 

with a grandchild, and are African-American or Latino. Nearly one-third of these 

households have to choose each month between purchasing food and paying for medical care and over one-third of these households have to choose monthly between 

buying food and paying for heat or other essential utilities. As a result, over 14 percent of individuals in the United States who seek emergency food assistance are 

over 65. Within slightly more than a decade, the number of seniors experiencing 

food insecurity is projected to increase by 50 percent when the youngest of the 

‘‘Baby Boom Generation’’ reaches age 60 (Coleman-Jensen, Nord, Andrews, & Carlson, 2012). 

Growing hunger and poverty merely constitute the tip of the iceberg. They reflect 

the widening gap in income, wealth, education, employment, and health status between classes and races in the United States. The relationship between family income and the lack of opportunity to escape poverty and its lasting consequences is 

clear. Yet, while there is a clear connection in the United States between poverty 

and unemployment, the possession of a job itself does not eliminate the risk of hunger. According to the Census Bureau, in 2010, nearly 10 percent of all American 

families, almost 21 million people, who are officially poor have at least one family 

member who is working (De Navas-Walt, Proctor, & Lee, 2011). Their poverty is a 

direct consequence of wage stagnation. From the late 1950s through the 1970s, a 

full-time worker earning the minimum wage could maintain a family of three at or 

above the poverty level. Today, this is no longer true (Economic Policy Institute, 

2012; Mishel & Shierholz, 2011). 

POVERTY AND HEALTH

Adults who are poor are more likely to have higher rates of heart disease, cancer, 

diabetes, and virtually every other major illness and cause of death (Kaler & 

Rennert, 2008). Among adults, poverty leads to higher incidences of diabetes, hypertension, cardiovascular problems; depression and other mental health problems 

among women, and, among pregnant women, more premature births, low-birthweight babies, and birth complications. For them, poverty and hunger are not merely statistics. They are, in the words of the Chilean poet, Pablo Neruda, ‘‘the measure 

of man.’’ 

Compounding these problems, people in poverty experience a wide range of disparities in health and mental health care. These include: (1) absence of care, especially preventative and primary care, rehabilitation services, long-term care, oral 

health, and the availability of affordable prescription medications; (2) poor access to 

care: over 20 percent of African-Americans and over 1⁄3 of Latinos have no health 

insurance and there is a maldistribution of health care providers in urban and rural 

51 

areas; (3) inability to afford adequate care as health care costs rise faster than inflation and States cut back funding for Medicaid; (4) inappropriateness of care, particularly a lack of sensitivity to the specific needs of impoverished persons among health 

care providers; and (5) wide variations in the quality of care. Today, the typical (or 

median) State provides medical assistance to working parents who make less than 

63 percent of the poverty line ($12,790 a year for a family of three) and non-working 

parents with incomes below 37 percent of the poverty line ($7,063 a year). Only a 

handful of States provide coverage to any low-income adults without dependent children, regardless of how far below the poverty line they fall. 

Let me illustrate these problems with some statistics from the Baltimore area 

where I live and work. In Baltimore, less than half of the population has a college 

education, the lowest percentage in the State of Maryland. Only 58 percent of city 

residents have incomes twice that of the poverty line. If 5 percent more people attended some college and 5 percent more had incomes higher than twice the Federal 

poverty level, we could expect to save 247 lives, prevent 27,000 cases of diabetes, 

and eliminate $202 million in diabetes costs every year. In Baltimore County, if 5 

percent more people attended some college and 3 percent more had an income higher than twice the Federal poverty level we could expect to save 266 lives, prevent 

305 cases of diabetes, and eliminate $2 million in diabetes costs every year. 

The lack of mobility out of low-income neighborhoods, particularly for racial minorities, compounds the health effects of poverty. Nearly half of African-Americans 

who live in high-poverty census tracts, for example, still reside in a high-poverty 

census track 10 years later Quillian (2003). In addition, 72 percent of African-American children who grew up in impoverished neighborhoods live in similar neighborhoods as adults. The absence of social mobility, generally associated with the American Dream, demonstrates that neighborhood poverty has prolonged and lasting consequences on the health, well-being, and life expectancy of poor children, particularly children of color. 

These consequences, however, are not limited to impoverished children. Each 

night an estimated 1 million Americans have nowhere to call home and over the 

course of any year 3 million Americans experience homelessness for an extended period (National Coalition for the Homeless, 2012). The U.S. Conference of Mayors’ annual survey of homelessness and hunger found that homelessness among families 

increased by 16 percent from 2010 to 2011, with unemployment, lack of affordable 

housing, and poverty being cited as the leading causes (U.S. Conference of Mayors, 

2011). For over 30 years, the impact of sub-standard housing conditions and homelessness on people’s health and life expectancy has been well documented. In 2005, 

the National Health Care for the Homeless Council reported that people experiencing homelessness are three to four times more likely to die than their housed 

counterparts, with the average age of death between 42 and 52 years of age 

(O’Connell, 2005). 

Individuals who are homeless are the most desperate of the over 20 million households (17.7 percent of all U.S. households) who pay more than half of their income 

for housing (Joint Center for Housing Studies, 2012). The absence of a sufficient 

supply of affordable housing contributes substantially to the high rates of poverty 

and near poverty in the United States and to the millions of Americans who are 

homeless, at risk of homelessness, or live in substandard, unhealthy, and often dangerous housing. To illustrate: A family of four with an income at the Federal Poverty Level ($23,050) has only 60.7 percent of the income necessary to afford a two 

bedroom apartment at the Fair Market Rent of $949/month; a single adult whose 

income is at the Federal Poverty Level has only 39.6 percent of the income required 

to afford an efficiency apartment at the Fair Market Rent of $705/month. To state 

this situation another way, a renter earning the minimum wage must work 101 

hours to afford a two-bedroom unit at the Fair Market Rent (Bravve, Bolton, Couch, 

& Crowley, 2012). Even an efficiency apartment is out of reach for the minimum 

wage worker, who earns 53.4 percent of the amount necessary to make market rate 

housing affordable. 

The impact of poverty on the health and life expectancy of millions of Americans 

illustrates the growing importance of our fraying social safety net. Without unemployment insurance, food stamps, Social Security, and the Earned Income Tax Credit millions more nationally would be vulnerable to the consequences of poverty outlined in my testimony. In 2011, these programs lifted 40 million people out of poverty, including nearly 9 million children. They lowered our official poverty rate by 

almost 14 percent. Given the long-term effects of poverty on people’s life expectancy 

and the damage it does to the well-being of our communities and our Nation, this 

is a time to expand and not reduce these essential life-giving programs. 

Thank you for your attention. 

52 


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Senator SANDERS. Thank you very much, Dr. Reisch. 

Many questions come to mind, but let me start off with Ms. 

Shrader. You grew up in a very poor county and in your testimony, 

you talked about some of the travails, some of the problems, some 

of the terrible things that happened to friends, and acquaintances, 

and family members who you grew up with. 

Can you say a few words about what life was like growing up in 

McDowell County? What happened to some of your classmates and 

family members as a result of the isolation and the reality of life 

in McDowell? 

Ms. SHRADER. Thank you. Drug abuse is a problem that is going 

on in that whole State of West Virginia, but I have seen family 

members and friends and classmates, a lot of them, get on drugs. 

All these people were born into poverty and fight to survive every 

day. They fight every day to get food, to pay their bills, and to have 

heat in their home. 

Senator SANDERS. OK. Thank you. 

There has been a recurring theme, I think, from almost all of the 

panelists that poverty for our country is, in fact, very expensive. 

That while some of our colleagues can say, 

‘‘We can save the Federal Government. Why do we not cut 

the TRIO program? We will save billions of dollars doing that. 

Why do we not cut Medicaid? We could save hundreds of billions of dollars.’’ 

I think what some of you are telling us is that that may not be 

the wisest course of action for some people. If they do not have access to healthcare, if they do not have access to education, if they 

do not have access to jobs and affordable housing, we end up paying not only in terms of human suffering and the shortening of life 

expectancy, but in actual dollars. 

Dr. Woolf, do you want to elaborate on that point, please? 

Dr. WOOLF. Senator, it is a key point. 

When we think about the burden on the Federal Government 

spending brought on by Medicare and Medicaid, children’s health 

insurance, and so forth, most experts recognize that a lot of that 

is being driven by the escalating epidemic of chronic diseases—diabetes, heart disease, and so forth—which accounts for the vast proportion of that spending, and those are diseases that are directly 

correlated to socioeconomic conditions. 

Another example similar to my colleagues’ presentations, we 

know that diabetes mortality rates for middle-aged adults are 3 

times higher if they have not graduated from high school compared 

with if they have some college education. 

59 

Those huge differences in the prevalence of these expensive 

chronic diseases cannot be ignored. Dealing with these socioeconomic conditions that affect educational attainment and socioeconomic status can markedly—— 

Senator SANDERS. Can I interrupt you? 

Dr. WOOLF. Please. 

Senator SANDERS. I am chairman of the Veterans Committee, 

and the V.A. actually does a fairly good job in addressing some of 

these issues. 

Is it fair to say that we know how to prevent, or at least cutback, 

on the incidence of diabetes if we invested in programs to do that? 

Dr. WOOLF. There is excellent research on important behavioral 

strategies. 

For example, the diabetes prevention trials have shown that intensive exercise and physical activity can reduce the incidence of 

new cases of diabetes by 15 percent. There are other strategies that 

we need to think about outside of the healthcare domain which is 

the focus of this hearing that can also exert tremendous leverage 

on the prevalence. 

Senator SANDERS. In other words, investing in those programs 

and cutting back on the incidence of diabetes may actually not only 

ease human suffering, but save money as well. 

OK. Let me ask. Several of you have made the important point 

that, shamefully, the United States has, by far, the highest rate of 

childhood poverty of any major country on earth; it is 22 percent. 

Given all that we have heard this morning, what do we look forward to? What is the future of this country when so many of our 

kids are living in poverty? When youth unemployment, an issue 

that is not discussed very much; we talk about real unemployment. 

Do you know what youth unemployment is? It is close to 20 percent 

in this country. Kids who leave high school, do not have a job, what 

happens to their lives? 

What does that mean in terms of life expectancy, human suffering, and the cost to the Federal Government? If a kid, a low-income kid, drops out of school as a junior in high school, what happens to that kid? 

Yes, Dr. Kindig. 

Dr. KINDIG. As I mentioned in my testimony, we know the effects 

of poverty and stress. There is a growing field in biomedical science 

about how early these conditions affect even within the womb, beginning with brain development. These things get set into life so 

early that it is such a compelling reason to start early because otherwise today the map for 20 years from now is being set in stone. 

I would just like to mention one other thing, Senator, that has 

not come up. Dr. Woolf and others have also shown in their work 

that in addition to our poor health outcomes in relation to other 

countries, we spend about one-third more in medical care than 

many of those that do better than us. We always wonder, ‘‘Where 

is the money to come from? ’’ But I am one of those who believe, 

with Dr. Berwick, who used to run the Center for Medicare and 

Medicaid services, that waste is theft. It is theft from these other 

kinds of investments that we know would be most health-promoting. There is a lot to be done there as well. 

60 

Senator SANDERS. Doctor, it is actually in many cases, more than 

one-third; it is almost double what other countries are spending. 

Senator Warren. 

Senator WARREN. Thank you, Mr. Chairman. 

I just want to pick up on the same theme. Let us start with the 

trend lines; where we are heading right now. According to the 

Commerce Department, inflation-adjusted incomes for middle-class 

families have dropped 6 percent just in the last decade. Meanwhile, 

the tax data show that nearly 20 percent of income in the United 

States last year went to the top 1 percent of earners. That is the 

largest share of income going to the top 1 percent since 1928; the 

Roaring Twenties. 

Now, economists agree that this kind of inequality is bad for 

growing an economy, but doctors, scientists, and health researchers 

are now teaching us that this kind of inequality is literally deadly 

for our families. 

What I wanted to start with is a question about what happens 

if these trends continue. If we continue to have an increase in financial inequality, what would be the impact on the health of families who are struggling to get into the middle class, or families who 

are trying to stay in the middle class? 

Dr. Woolf, could you start us on that? 

Dr. WOOLF. I am glad you brought it up, Senator Warren. The 

focus, obviously, in the last few comments has been on poverty, 

which is obviously a great concern, but these economic trends 

across the entire middle class of the United States also carries significant health implications. 

This trend of increasing income inequality and decreasing median household income has been going on for some years now. It 

is getting worse. And we know from a public health standpoint that 

that carries important health consequences. What it means to Senator Sanders’ point is that our children that are growing up under 

these conditions—we are raising a generation that is going to be 

sicker. 

When we think ahead to what the implications are, besides the 

obviously important human toll that that will inflict on that generation of higher chronic disease rates, that means a sicker workforce, a less well-educated workforce, and for American businesses 

greater difficulty competing against other countries where they 

have less expensive healthcare costs and healthier populations. 

Senator WARREN. Is there anyone who wants to add that? 

Mr. Reisch. 

Mr. REISCH. Yes, I think we are talking about a situation right 

now which is creating a lack of mobility, both physical mobility and 

social mobility for millions and millions of people. 

For example, it is harder and harder for low-income and working-class families, and even middle-class families, to go to college 

today. The cumulative amount of college debt now is higher than 

the total credit card debt in the United States. This is locking people into a lifestyle and physically into communities which we know 

are less healthy and less able to access all the benefits of our society. 

Three-quarters of all African-American children who grow up in 

low-income neighborhoods will remain in those neighborhoods as 

61 

adults. We are talking about creating a permanent social stratification in our society which is socially unstable, politically unstable, 

and economically damaging for our country because we are depriving our Nation and individual people of being able to contribute to 

the economic growth, prosperity, and well-being of our whole society. 

Senator WARREN. Thank you. 

Dr. Berkman, did I see that you wanted to add to that? 

Ms. BERKMAN. I was just going to say that to increase this, that 

the trend lines are bad and we see this evidence in health and retirement survey, where we see cohorts have increased morbidity, 

higher rates of diabetes, higher rates of heart disease, higher rates 

of blood pressure. We see it in children as well, who seem sicker, 

are more likely to be obese than their counterparts a cohort or two 

ago. 

I think the most important thing when we think about this is 

that—and what you are onto—is that the social and economic policies that Government has developed over years that may be healthpromoting are not counted as being health-promoting. We do not 

think about that and the benefit side of the equation. 

We only think about them in terms of the short-term economic 

turnaround, or employment, or labor. When, in fact, the spillover 

to health may be enormous and kind of trumps many, many other 

health policies that we have. 

Senator WARREN. Let me pick up on this, then, because what I 

am hearing from all of you is that we seem to be caught in a vicious cycle here. That we have got struggling families who are 

more likely to get sick and once someone is sick, that puts even 

greater strain on the family. So that that puts more strain on the 

family budget. It reduces the ability of parents to work. It causes 

further financial struggles and we get a real downward cycle here. 

So the question is: how do you break out of that cycle? What are 

the options available to us to move away from this? Dr. Berkman, 

you have identified one. If we change that calculation on how we 

understand costs and benefits, that we could make different kinds 

of investments that would be financially sensible investments, but 

we have to do the full accounting. 

What other ideas should we put on the table to address? 

Dr. Woolf, did you want to add something more? 

Dr. WOOLF. We have an initiative at our Center that we call 

Connecting the Dots, and it is basically this notion that Dr. 

Berkman is mentioning of understanding how these policies—that 

are not conventionally thought of as health policies—are vital levers for affecting health outcomes. 

One example I will talk about is education reform. Our efforts to 

try to improve education beginning with preschool or early childhood education, all the way from K–12, in helping our young people 

achieve a college education and a graduate school education are 

vital in a knowledge economy that are also key levers in improving 

health outcomes. 

A lot of the socioeconomic problems that we are talking about 

here would be powerfully addressed by improving the educational 

success of our young people. The U.S. rankings on education are 

slipping behind other countries. We used to be the most educated 

62 

population post-World War II. Now our seniors are the most educated seniors in the world, but our young people are falling behind 

not only industrialized countries but emerging economies because 

of our shortcomings in education. 

Senator WARREN. Mr. Chairman, can I have just another minute 

to let others respond? Is that all right? I think Dr. Eberstadt wanted to respond and I wanted to give him a chance. 

Mr. EBERSTADT. Thank you, Senator. 

It is important to understand the role of social forces in health 

outcomes in the United States and elsewhere. But it is also important to understand the role of human agency: of lifestyles, and behaviors, and practices, and outlook, and attitudes, and objectives. 

If social forces were really the determinative, the Latino health 

story in America could not have occurred. We should want to understand how disadvantaged groups in America—how people with 

less privilege, less education, less income—sometimes have excellent health outcomes. I think this is some of the low hanging fruit 

in our situation today. 

One of the reasons, perhaps, that we do not know as much about 

this as we might has been that we have skimped on investments 

in social and economic data systems for our country as a whole. We 

were once not just the envy of the world with our educational results; we were the envy of the world with our statistical system. 

That is not true anymore. 

We have held back on the investments in these data systems 

that, I think, would help explain much more what is going on in 

America. 

Senator WARREN. That is very valuable. Are we still OK or do 

you want me to do another one? 

Mr. Kindig. 

Dr. KINDIG. Just to build on that. 

Senator WARREN. But be really short here. 

Dr. KINDIG. Yes. Not only are the data systems, we just need the 

dollars to invest in research and understanding what are the most 

important factors. 

We are pouring zillions of dollars into studying which kinds of 

medical care factors are better than others; which drugs, which 

procedures. That is important work to do. I do not mean to bash 

that. But we spend almost no money on the questions before you 

here. 

What are the most cost-effective relative investments across the 

determinants so that we can get a balanced investment portfolio 

that will change the colors of these maps? 

Senator WARREN. Thank you very much, Mr. Chairman. 

Senator SANDERS. Very important point. Let me change gears a 

little bit and Ms. Shrader, I am going to get back to you, but I 

want to ask the doctors here a question. What is the physiology of 

stress and poverty? 

In other words, when most people think about poverty, they say, 

‘‘Well, it is too bad. You have a broken down car; I have a 

nice car. You live in a small apartment; I got a really nice 

house. That is my advantage over you.’’ 

63 

But stress and poverty, wondering how am I going to feed my 

family tomorrow, pay my bills, get the income I need to survive 

takes a toll on human life, does it not? 

What is the physiology between somebody who has a meaningful 

job, is earning a decent income, is married, has good social relationships and somebody who is in a very different position? What happens physiologically, if you like? What does that do to the body? 

Who wants to comment on that? 

Dr. KINDIG. I will be happy to start and I am not an expert on 

this, but there are really two pathways through which these income and educational disadvantages get under the skin. The one 

is obviously if you do not have education or income, you cannot get 

a good job. If you do not have income, you cannot get health insurance, you cannot go to the fitness center. Those sorts of things that 

you cannot do. 

But more and more research these days, high quality research is 

showing what you said, Senator Sanders, the stress pathways independent of those other factors, that operate really through neural 

endocrine mechanisms and neuro-immunological mechanisms that 

really puts the body under stress that produces some of these impacts on length of life and on disease. 

That is really a body of research of the last 10 or 15 years that 

is becoming unimpeachable and it happens early. That is another 

matter. It begins to happen early. 

Senator SANDERS. Dr. Reisch. 

Mr. REISCH. Yes, thank you. 

I am not a medical doctor, but the studies that demonstrate that 

the lack of choice and the increased stress that low-income people 

experience increases their level of cortisol, and we know that higher levels of cortisol are correlated with cardiovascular disease and 

other chronic illnesses including diabetes. 

There was a study done in Louisville, KY, for example, which did 

a very interesting analysis of the city based upon the quintiles of 

income level. It demonstrated that morbidity and mortality rates 

varied in exact correlation with social stratification in that city. 

And I think the same thing applies in places like Baltimore and 

Washington as well. 

Senator SANDERS. Yes, Dr. Berkman. 

Ms. BERKMAN. I would just add that I think there are multiple 

pathways that lead from socioeconomic conditions to poor health 

outcomes. One of them is behavioral. 

People tend to smoke more. They tend to consume more alcohol. 

They tend to be more overweight. They make harder food choices 

in part because of transportation needs and food. But these stress 

pathways are also independent of that. It is very clear that these 

behavioral pathways only explain a part of that. 

The stress pathways influence such things as inflammatory 

markers, as other people have said, cortisol responses, inflammatory markers and works with things like people sleep less. People when they are stressed sleep less. We now know that less sleep 

is related to metabolic function. It is related to depression. These 

things also influence diabetes, cardiovascular disease, hypertension, and a host of other chronic diseases. 

64 

They also put you at risk for a whole set of mental disorders that 

are very important and often underestimated in these set up equations. 

Senator SANDERS. I think, as Senator Warren indicated, we have 

a chicken and egg situation. When you are under stress, it’s hard 

to get a decent job. When you do not have a decent job, hard to 

have an income to alleviate the stress again, so housing and 

healthcare and everything else. 

Let’s jump a little bit. Dr. Woolf, you may have done the research 

on this. How do we do as a Nation? Why is it that a Nation which 

is as wealthy as we are does not do particularly well compared to 

many other countries around the world in terms of life expectancy? 

How does that relate to this whole discussion? 

Dr. WOOLF. To repeat the point that has been made earlier, we 

have higher poverty rates and higher income inequality levels than 

they do in those other countries. That is certainly part of it. 

But in our analysis, comparing the United States with the 16 

other high-income countries, it is also clear that, obviously, they 

have poverty in other countries too, but there appears to be more 

programming and policies in place in those other countries to buffer the impact of material deprivation on families. So that, in effect, 

children growing up in poor families in these other countries are 

more protected from the adverse health effects than American children are. 

Our relative investment in those social programs, social services, 

is quite striking. Elizabeth Bradley and her colleagues at Yale University have compared the United States with these other countries 

and find that we are an outlier in the proportion of our dollars that 

we spend on healthcare relative to those social programs. Whereas 

the countries that spend much more on social programs than on 

healthcare are the ones that are living longer. 

Senator SANDERS. And presumably saving money on healthcare 

as well. Other thoughts on that? 

Senator Warren. 

Senator WARREN. I just wanted to dig-in to this point a little bit 

more. Thank you. 

And that is, I was thinking about this, so healthy people have 

stable, safe, clean housing. They live in safe neighborhoods with 

sidewalks. They have lots of outdoor spaces. Healthy people can afford nutritious food. Healthy people have clean air to breathe. For 

many Americans, these necessities of good health are luxuries they 

cannot afford. 

If we have a system that is not investing in these cost-efficient 

ways to keep people healthy, and a system that wastes far too 

much money treating people after they become sick, it is no wonder 

in this system that Americans are less healthy and die younger 

than people living in other wealthy Nations. 

But I wanted to dig-in to that just a little bit more, Dr. Woolf, 

if I could. Can you tell us about the basic investments that other 

countries in the Institute of Medicine’s study make outside direct 

healthcare investments that have helped them achieve better outcomes? 

Dr. WOOLF. Well, due to the paucity of data that Dr. Kindig mentioned, it is really hard to prove cause and effect. 

65 

Senator WARREN. Fair enough. 

Dr. WOOLF. But we can see that these other countries that have 

better health outcomes have different policies with respect to some 

of the areas that Dr. Berkman mentioned, such as parental leave, 

maternity leave, early childhood education. We are outranked by 

other countries in the amount of resources they invest in early 

childhood education. Job support and workforce support for workers are more extensive in these other countries. 

Again, these are programs and services that help buffer the potential adverse health impact on families that we think might 

produce potential health benefits. But if I may step back out of my 

medical roles, those are also policies that help people achieve a 

stronger economic footing and increase their economic prosperity so 

that they could be more productive workers, more affluent consumers and so forth, and therefore boost the economy. So it is a 

win-win improving their economic footing and their health outcomes. 

Senator WARREN. The virtuous circle instead of the vicious cycle. 

Dr. WOOLF. Exactly. 

Senator WARREN. Maybe I can ask this in a more detailed, in another way. Dr. Kindig, I think in your written testimony, you 

talked about Cambridge and Fall River, MA—you knew you would 

catch my attention with that—how they made smart, communitybased investments. 

I am going to ask you just to say a bit more about it, and talk 

about how we could apply some of those same strategies to the 

broader population, and what the major barriers are that stand in 

our way right now. 

Dr. KINDIG. Right. Thank you for bringing up that point. The 

time limitation, I could not say everything that I wrote, but I was 

actually calling attention to a new program that we work with at 

the University of Wisconsin along with the Robert Wood Johnson 

Foundation. It is called the Roadmaps to Health Prize. It sort of 

is a companion to the County Health Rankings work that I mentioned before. 

We are, the Foundation and with our staff, are every year looking for those communities, not just the highest ranking communities. That is what our rankings do. They are the highest because 

they have all these things going for them. 

We are actually looking for American communities that have 

shown that they can be improving their health outcomes with a 

balanced approach like we have just been talking about. Not just 

in medical care, but actually in order to get a prize, you have to 

show excellence in the behavioral area, in the socioeconomic area, 

in the healthcare area, and particularly looking for multi-sectoral 

approaches. 

So the two places in your State, that was a little embarrassing 

to give two to the one State, but sometimes—— 

Senator WARREN. We are working on it. 

Dr. KINDIG. Yes, I know. But both of them, very different communities as you know. 

Senator WARREN. Yes. 

Dr. KINDIG. But very remarkable partnerships coming together 

with the healthcare community, the public health community, the 

66 

business community, community nonprofit organizations, United 

Way, sort of come together and say, ‘‘We got a problem here to 

solve and how can we pull together to do it? ’’ 

Over time, this will be an ongoing, very high profile program 

with the Robert Wood Johnson connection, over time with six every 

year. When we get 20, 30, 50 of these type communities, there will 

be little stories there that other places can emulate and these are 

not the best-off places. Many of these are challenged, as Fall River, 

for example, is a challenged community for many historical reasons, but they are finding a way to do it. There are stories that we 

can look to, to make progress, and thank you for bringing attention 

to that. 

Senator WARREN. Well, thank you. Thank you, for your bringing 

attention to it because I think it is a reminder. We can do this in 

the United States. We have little pockets of where we have begun 

to build on the research that you all and the advice that you all 

have given. We just need to find ways to support it and extend it 

across the country. 

Thank you. 

Senator SANDERS. Let me ask, start with Dr. Kindig to elaborate 

a little bit on a paper that he wrote earlier this year which showed 

that female mortality rose in 43 percent of U.S. counties between 

1992 and 2006, and that is almost incomprehensible. We talk about 

all of the advances we are making in all kinds of areas, and yet 

in 43 percent of the counties in America, women are living shorter 

lives. 

What is that about? Why is that taking place? 

And then I want to ask Ms. Shrader if she could, again, coming 

from a county where life expectancy is low, to maybe talk a little 

bit about women in those counties and how Dr. Kindig’s statistics 

are reflected in the real life that she may have observed. 

Dr. Kindig. 

Dr. KINDIG. Yes, thank you, Mr. Chairman. I have to tell you 

honestly that when I saw that map, when my colleague Erica 

Chang, one of our doctoral students, brought that map in, I said, 

‘‘I do not believe this.’’ We did two things that are different. 

One is we looked at change over time and that is not often looked 

at. This is a change over time thing as opposed to how it is in a 

certain time. 

We also looked at the county level. When you look at Nations 

and States, almost always mortality and life expectancy go up because you average in the poor and the—but when you go to the 

county level and look at change over time, these are the kinds of 

results that you get, and we were shocked. We are not the only 

ones that have found that. 

Chris Murray and his colleagues at the University of Washington 

have looked at also declining life expectancy, showing also not 

quite as—it was a different data set in a different time period. 

Senator SANDERS. But as I looked at that map, sorry to interrupt 

you, if I look at that map, there is a lot of red in the southeastern 

part of the country. Out in California and southern California, it 

is all blue. 

Dr. KINDIG. Yes. 

Senator SANDERS. What is that about? 

67 

Dr. KINDIG. In all of those counties, all the poor performing counties have high rates of smoking, high poverty, children in poverty, 

low high school graduation rates. They have all those factors. 

One of the striking things that we found and, actually frankly, 

Senator, that I do not understand, when actually you control for all 

of those factors, there still are regional effects in the South and 

parts of the West that we do not understand. We say in our paper 

there must be other cultural or other factors that even go beyond 

the disadvantage that these counties have from poor rates of the 

factors that we know about, and it needs to be—I am quite interested in why that is. 

I have to tell you, most of the reports—and we have paid a lot 

of attention to this—ask, ‘‘And why is this more for females than 

for men? ’’ We do not honestly know the answer to that, but I know 

a lot of people are trying to dig-in to it and that is why we need 

more research funding to answer these kinds of questions. 

Senator SANDERS. Ms. Shrader, do you have any thoughts on 

why that might be the case? Why is it conceivable that in America—and in West Virginia among other places—women are actually 

living shorter lives than used to be the case? Any thoughts? 

Ms. SHRADER. Basically, they are working so hard and while they 

are working so hard, they are suffering to make their basic needs 

and to make their family’s needs such as food, clothing, and shelter. They do not have what they need to succeed. They are stressed 

and overworked, but it is not their fault. They need services and 

programs to help them improve. Examples of how they are working 

so hard as they are trying to be mothers, they are trying to work 

jobs, they are trying to get an education. They know what the research says. 

The research teaches children what you need to succeed, but if 

you do not have it, you have to improvise and utilize all of the resources and all of the people that is in your community and your 

churches and in your family to try to do your best with what you 

have, and hope that you are going to succeed. 

Senator SANDERS. Let me ask you maybe a dumb question here, 

but is it your observation that a lot of folks are smoking and not 

eating well in these communities? Is that something, too? 

Ms. SHRADER. There are a lot who are. However, farm to school 

programs are coming into play in West Virginia. I have seen them 

come into play in the northern-central parts of West Virginia. They 

have yet to be big and booming in the southern parts, but they are 

getting there. It takes time. 

Senator SANDERS. You made the point earlier, that just programs 

like the TRIO program or Upward Bound giving kids the opportunity of even knowing what a college is. You made an interesting 

point that there are many kids that you have grown up with who 

have never seen a college campus in their lives. Exposing them to 

those opportunities has an impact on young people’s lives, would it 

not? 

Ms. SHRADER. It definitely does. When you are not exposed to opportunities, period, in the world, you only know what exists by 

what you see. There are all kinds of things on TV that are not real, 

but they just may not know what they can do. 

68 

Also, sometimes you get told things that are not true. You get 

told, ‘‘You are stupid.’’ Or, ‘‘You are not going to amount to anything.’’ A lot of times kids are told this when they are kids, and 

they end up believing these things, and it ends up becoming a selffulfilling prophecy. They do not believe in themselves. It is real 

hard for them to try to do better. 

Senator SANDERS. You mentioned to me last night when we chatted, Ms. Shrader and her husband and I chatted a little bit, that 

there are a lot of kids who have never left their county or left the 

State to see the rest. Well, it is true in Vermont, as well, by the 

way. Elaborate a little bit on that. 

Ms. SHRADER. Well, there are a lot of people in McDowell County 

statistically that do not have transportation. It is not that their 

parents do not want to show them other parts of the world, or 

other parts of the West Virginia, or other parts of the country; they 

may not have access themselves to teach their kids what is out 

there. 

A way that they can learn about it is if other family members 

have traveled, been in the military, for example. They come back 

and they tell their stories. We all try to teach each other about 

what is going on in the world. 

Senator SANDERS. Let me change gears a little bit. 

Dr. Woolf made the important point, I think, that diabetes is 

much more prevalent among lower income people at great cost to 

the individuals and financial cost to the country. Go beyond diabetes in terms of obesity, in terms of smoking, in terms of child 

abuse. 

How does class impact those factors, which play such an important role in our lives? 

Dr. WOOLF. It is a pervasive issue. There are some diseases 

where we do not see it quite as dramatically, but a very broad spectrum of conditions that have these strong socioeconomic determinants. 

In addition to diabetes, I had mentioned cardiovascular disease, 

pulmonary disease, arthritis, mental illness, depression, for example, much higher rates. Studies that have looked at disability rates 

and the productivity of workers also find striking differences by 

educational attainment. 

So that, again, is a factor that is affecting life expectancy, it is 

affecting health burden. 

Senator SANDERS. Something as simple as, say, smoking—and I 

do not know the answer to this—is it fair to say that working-class 

people are more likely to smoke than upper income people? 

Dr. WOOLF. There is a strong gradient in smoking rates based on 

socioeconomic status since the release of the Surgeon General’s Report in the 1960s that revealed the role of smoking. We see that 

in upper educated Americans, there was a striking decrease in 

smoking rates. But in Americans with less than a high school education, smoking rates are about triple of those with more advanced 

education. 

Senator SANDERS. Which is going to lead to a whole host of 

health problems, obviously. 

Dr. WOOLF. Exactly. 

Senator SANDERS. Senator Warren. 

69 

Senator WARREN. Thank you, Mr. Chairman. 

I would like to go back to a point that, I think, several of you 

have emphasized, and that is one way to decrease the health disparities between high-income and low-income people is to look at 

the environments around them. 

I am proud that in Boston, we have a model program, the Asthma Prevention and Control program that is run by the Boston Public Health Commission, and it has demonstrated success in reducing asthma in our struggling neighborhoods by doing exactly that. 

I just want to talk about the program for a minute. 

The Boston program addresses environmental triggers of asthma 

by eliminating the pests that trigger asthma in our homes, and by 

ensuring that the pesticides used to control the pests are not themselves toxic. 

The Boston program does home inspections to make sure the 

property owners are keeping the residences up to code. The Boston 

program performs home visits to teach families how to reduce asthma and they teach in the language that the family speaks. They 

give them the tools to prevent allergens in the home. 

The Boston program has been under the leadership of the executive director, Dr. Barbara Ferrer, and the director of Healthy 

Homes and Community Support, Margaret Reid and it has just 

been an incredible success. I want to tell you about some data that 

are not yet published from this. 

A forthcoming report shows that the number of families who 

have recently visited an urgent care for asthma dropped from 80 

percent to 20 percent after participation in a home visit program. 

In the public housing that was eradicated of pests, the number of 

adult residents with asthma symptoms was cut in half. 

We are working to expand this initiative across Massachusetts 

because we have seen it work. So what I want to ask you to do is 

talk to us about how we implement programs like this on a larger 

scale, not just for asthma, but for the many diseases where we 

know that if we can improve environmental factors, we can get better health outcomes at lower costs for our citizens. 

Who would like to do that? Dr. Berkman. 

Ms. BERKMAN. First of all, I would like to congratulate you on 

congratulating Barbara Ferrer, who has done an amazing job. 

Senator WARREN. Is she not fabulous? 

Ms. BERKMAN. A completely amazing job in Boston city in terms 

of understanding, really, the social determinants of health approach. She is an enlightened person in terms of doing this. 

I think the point of it is that once you understand that the determinants of health fit in neighborhoods, in schools, in worksites, and 

you start turning your attention to what it takes to improve those 

settings, there are millions of things to do. There are sets of things 

in housing that get turned around. There are sets of things in 

schools that we could be doing. 

And worksites, I think, are enormously hopeful because people 

think that this is costly when, in fact, most companies actually 

once they realize what is going on, think that it is better for the 

bottom line. Our nursing homes, for instance, think that turnover 

and sickness absence is devastating their bottom line. And that 

70 

these workplace policies will improve their bottom line and be good 

for the health of workers and their families. 

I think if Barbara were multiplied times 100, that you would like 

to get that kind of message out. 

Senator WARREN. So there is one strategy. We multiply Barbara 

times 100. 

Ms. BERKMAN. Yes. 

Senator WARREN. Again, I very much get the point. I think it is 

a really powerful one. 

Dr. Kindig, do you want to add? 

Dr. KINDIG. I would like to add to that. A lot of this work is going 

on. That is the really wonderful example. But a lot of this work is 

going on in communities in different places, public health departments, but the resources that support it are idiosyncratic, and fragmented, and come and go so that it is not a sustainable model to 

scale. 

I really think we have to find the same kind of resources that 

deliver on this as we do in our healthcare programs. Every Medicare patient that is treated, there is a little bit of dollar that goes 

into graduate medical education, as you well know. You do not 

have to put in a grant. It just happens every day. 

We need those kinds of resources. Hooking back to my other comment about waste in healthcare, as we squeeze the waste out and 

find the savings. So what is going to happen? Let us say we are 

successful at that. We will see. So who gets the savings, you know? 

Right now in accountable care organizations, they are talking 

about shared savings between the insurers and the providers. 

There is nothing wrong with that, but a number of thoughtful people have been talking about what about a community part of the 

shared savings to go to these other nonmedical care programs like 

you mentioned, housing lead abatement or roach abatement that 

are, undoubtedly, health-promoting. But where are the sustainable 

resources to sort of deliver a dollar every day to the places that 

need it? 

Senator WARREN. Dr. Reisch. 

Mr. REISCH. Thank you. I think it is also important, as you suggested in your description of the program in Massachusetts, to 

focus on community investment and community involvement, and 

not just focus on individuals. 

Individual and community behaviors are clearly linked, and let 

me give you an example in terms of Baltimore, where there has 

been an effort to reduce or eliminate the number of food deserts in 

the city, which has been shown to be a major cause of people’s poor 

diets, which in turn, leads to obesity, which in turn, leads to diabetes and cardiovascular disease. 

There have been efforts, for example, to involve the community 

in helping to site supermarkets, which bring healthy food choices, 

to establish food co-ops, to establish farmers markets in the community, to create community gardens, and so forth. Well, those 

things not only have a positive effect upon people’s health individually and collectively, but also by involving the community in it, it 

builds the community’s capacity to produce future changes and improves their psychological well-being as well. 

Senator WARREN. Thank you very much. 

71 

Thank you, Mr. Chairman. I just want to say, since this is my 

last round of questions, when we look at data like this and we see 

that just cleaning up the environment means that we cut visits to 

the emergency room for children with asthma from 80 percent to 

20 percent, that is not only economically sound. That is a lot of little kids who stayed in school those days, or who were outside playing, or who were having fun instead of spending their time in very 

expensive and very scary emergency rooms struggling to breathe. 

If those are not the investments we are willing to make, what 

kind of a people are we? We have opportunities here. We just have 

to seize them. Thank you. 

Thank you, Mr. Chairman, for doing this. 

Senator SANDERS. Well, thank you very much, Senator Warren. 

I did not want to leave Dr. Eberstadt out of the discussion here 

because I think you made some good points. I think your point was 

that we should take a hard look at why it is that Asians in this 

country, Hispanics in this country have better life expectancies 

than their socioeconomic conditions would allow us to assume. 

Do you have any guesses as to, in fact, why that is the case? 

Mr. EBERSTADT. It is a really important question, Senator. It is 

a really, really under-researched question. I hope that you all can 

encourage some more research in this area. As Dr. Kindig mentioned, this is a very underfunded area also. 

I am just so struck by this Figure 8 in my prepared testimony, 

which shows life expectancy in New York City by ethnicity and by 

neighborhood status. You see on here that the healthiest group in 

New York City, according to the New York Department of Health 

study, are Asian-Americans who live in the very poorest neighborhoods. 

Senator SANDERS. By ‘‘healthy,’’ do you mean life expectancy? 

Mr. EBERSTADT. I am using that, yes, as a proxy. 

Senator SANDERS. Life expectancy. 

Mr. EBERSTADT. I am using that as a proxy. 

Senator SANDERS. Would you guess that maybe it has something 

to do with family structure and so forth? 

Mr. EBERSTADT. That is the ghost in the room that has not been 

mentioned yet, sir. There is, I think unfortunately, a wealth of evidence that suggests there is a correspondence between family 

structure and health outcomes, family structure and poverty outcomes. 

The fraying or disintegration of the U.S. family structure for all 

ethnic groups over the past 50 years, has had really frightening 

consequences. One of them is that a child in the U.S.A. is more 

likely to live with just one parent today than in any of the OECD 

countries, or at least the never-communist OECD countries. We 

have a higher proportion of children living with one parent than famous Scandinavia. 

Senator SANDERS. I think that is a good point. 

If I can, because Senator Warren and I are the only people here, 

we have all the time we want. I wanted to throw out another point. 

Dr. Kindig, the word ‘‘community’’ came up a whole lot, and I 

think how we relate in the community, whether we feel isolated or 

alone, or we are part of something larger than that, I suspect plays 

a role in everything that we have been talking about. 

72 

I have worked very hard, with some success, to expand community health centers in the State of Vermont and throughout this 

country. 

Just as an example, just a couple of weeks ago HRSA, HHS, an- nounced they were going to spend $150 million—which around here 

is not a lot of money—in starting up 236 new community health 

centers in almost every State in this country providing healthcare 

access to about 1.3 million people. 

We talk about community. What impact does it have? The basic 

point is made over and over again is that healthcare is a lot more 

than health care. Right? 

But on the other hand, if you have a community health center 

where people can walk in the door and get the healthcare they 

need when they need it, not delay going to the doctor, get low-cost 

prescription drugs. Get mental health counseling when they need 

it. Get dental care when they need it. To give you an example. 

Northern Vermont has a community health center, I visited them 

during the summer. You know what they were running? They were 

running a summer camp for virtually all the kids in the town because they do not want kids hanging out on street corners. 

I was in the Bronx, NY at a community health center. They are 

involved in food, making sure that kids are eating well. They are 

involved in pregnancy prevention. They are dealing with how to 

prevent AIDS, et cetera, etc. 

I understand, again, that the main point of today is healthcare 

is more than health care. But what would it mean to this country 

if in every community in America, people could walk into their doctor’s office when they needed to and get the broad counseling that 

they needed regardless of income? 

What impact would that have on longevity? 

Dr. Kindig. 

Dr. KINDIG. Yes, I really want to take this because I think I told 

you in my testimony that I actually came of age and I am probably 

the only one here who knows what OEO was, the Office of Economic Opportunity. 

Senator SANDERS. Not the only one. 

Dr. KINDIG. I came of age in an OEO neighborhood health center 

in the South Bronx and even before federally qualified status. Your 

point is so well-taken, Senator. Not only at the time, at that time, 

were those health centers innovative ways of getting access to medical care which, of course, is a determinant of health. We are not 

saying medical care is not a determinant of health. It is just not 

the only one. 

At that time those centers, particularly in that time, were actually the hubs of other kinds of social services like school programs, 

job training, and legal advocacy. It was just part of the package. 

I believe as over the years, particularly as OEO funding went 

away, some of those other services fell off a bit, quite a bit, even 

though the medical care role remains. I think many health centers 

do, like you say, do-do that. 

If you have another $150 million, I think you ought to not only 

expand those health centers, particularly in the under-served communities that need it, but make sure that they have the resources 

to be a focal point, at least in those communities, for this broader 

73 

range of services like your asthma program, or school health, or 

whatever that would be responsive to the issues that we are talking about here. 

Senator SANDERS. Many of them do an extraordinary job, and 

they are all different. The one in the Bronx was different than the 

one in northern Vermont. But they look at the community as a 

whole and they say, ‘‘How do we keep people healthy? Yes, we are 

going to treat them when they get sick. But how do we keep them 

healthy? ’’ How can you ignore when the school down the block is 

not doing a good job? Where there is not a grocery store that people 

can buy decent food? 

I think having professionals and having that kind of community 

health center means a lot. But does anyone want to elaborate on 

that? Yes, Ms. Shrader. 

Ms. SHRADER. Thank you. I just wanted to point out that I am 

a fish-eating vegetarian. I lost 80 pounds in the past year. This was 

after I watched the documentary on Netflix called ‘‘Forks Over 

Knives.’’ 

Research was done in Asia. These doctors saw where the people 

in Asia were not dying from strokes, heart attacks, and diabetes. 

And what they found is that they were so poor, they could not afford meat. Once they made it into the middle class, and they started eating meat, they started dying from high blood pressure, all 

those issues. Thank you. 

Senator SANDERS. Dr. Reisch, did you want to? 

Mr. REISCH. Yes, I think it is also important to add that access 

means more than just physical proximity. It also means the likelihood that the services that are provided are going to be more culturally compatible to the needs of the community because the community is involved in determining what those services should be 

and what constitutes an appropriate service. 

When I was growing up in public housing, we had a public 

health nurse who was located on the grounds of the housing 

project. That is where I got my childhood immunizations. The startling statistic, which I think my public health colleagues can validate, is that fewer children in the United States today are immunized than that in Mexico, and that is something that we should 

be totally ashamed of. 

Senator SANDERS. Yes, Dr. Kindig. 

Dr. KINDIG. Just building on the other point about the health 

centers, and I cannot support it more than I did. But it is a big 

country and I think we are going to find that different solutions, 

even from where the organizing principle is, maybe take place in 

different ways. 

When the two communities that Senator Warren mentioned that 

won the prize, one in Fall River was a very unusual, just sort of 

a grassroots community organization that has grown over time and 

they seem to have the leadership. The other one in Cambridge is 

a combination of public health and innovative healthcare system. 

One in Santa Cruz, CA, it was a United Way that actually was the 

glue that pulled the partnership together to make this happen. 

I think centers, community health centers, can play a real important role in many places. But there may be other ways in other 

places given the history and the nature of the community efforts. 

74 

Senator SANDERS. Senator Warren. All right. First of all, thank 

you so much, Senator Warren, for staying here throughout. 

I think this has been a great discussion, I really do, and I think 

you have shed light on issues that we just do not talk about often 

enough. I think the point that you have made, if we invest in our 

people, create a healthier, more loving society, we end up not only 

creating a happier society with people that are going to live longer 

lives. But you know what? We end up saving money as well. We 

end up saving the taxpayers’ money. 

You guys have just been terrific and we appreciate, very much, 

all of you for being here. 

The record will remain open for 10 days to receive any additional 

comments. 

Thanks very much. 

[Whereupon, at 11:40 a.m., the hearing was adjourned.] 

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