The Good Life: Working Together to Promote Opportunity and Improve Population Health and Well-being

Lifeexpectancy is loweranddiseasemorbidity ishigher in the United States than in other high-income countries.1 This situation, decades old, is not for lack of skilled medical care; the United States has among the world’s best hospitals and technology. Nor is spending on health care inadequate; per capita health expenditures in the United States far exceedspendingelsewhere.Thepoorerhealthof racialandethnicminorities does not explain the nation’s low rankings; the US non-Hispanic white population and other advantaged groups also have worse health outcomes than their peers in other countries.1,2 TheUShealth care systemcertainlyhasdeficiencies,notably the lackofuniversal coverage,but this alone does not explain the pervasive health disadvantage. Health is aboutmore thanhealth care,withhealth care accounting for only an estimated 10% to 20% of health outcomes. As reported in JAMA 23 years ago, the nation’s major diseases havemore to dowith unhealthful behaviors—for example, smoking—than health care.3 Overenthusiastic advocates of personal responsibility, however, often blame poor health entirely on individuals and their imprudent habits. Behaviors are notoriously difficult to change, even among the affluent, and they are often influenced by environmental factors beyond personal control. This is especially true in low-income communities, where healthful food, parks, sidewalks, playgrounds, and physicians are often scarce. The socioecologicalmodel of health recognizes that proximal health determinants such as medical care and individual behaviors are influencedbysocioeconomic circumstancesand the environment, all of which are shaped by macrostructural factors suchaspublic policies.4 Foremost among the social determinantsofhealth is education,whichprovidesapath toemployment, income, and the skills for social mobility. Collegeeducated adults have substantially lowerdisease rates thando thosewithout a high school diploma.5 Although these disparitiesprobablyhavemore todowith incomethandiplomas,data about the income-health gradient aremore limited. Income is a sensitive topic for surveys to explore and, unlike education, is not recorded on death certificates (and thus vital statistics). In this issue of JAMA, an important study by Chetty and colleagues6shedsnewlightontherelationshipbetweenincome andlifeexpectancy.Usinginnovativedatasources(taxandSocial Securityrecords), theauthorshaveelucidatedthestructuralform of the relationship and unearthed fascinating details about its evolutionovertimeandacrosscommunities.Forexample,based onpooleddatafrom2001through2014, theycalculatedthat the gap in lifeexpectancyfor therichestandpoorest 1%of individualswas 14.6years formenand10.1years forwomen.Lifeexpectancy, and its changes during these years, varied substantially by region. The study only examined life expectancy at age 40 yearsby incomepercentile; lifeexpectancyatbirth, themorefamiliar statistic,may be affected differently by income. The authorsalsoexcludedpeoplewithnoincome.Althoughtheincomehealthrelationship ismediatedbyneighborhoodconditions, the authors limited their analysis tobroadgeographic areas (aggregationsof counties). Their article reported trendsonly for areas with more than 590000 persons, thus excluding some rural areas,buttheir findingsfor100populatedlocalities isagreatservice to local leaders and residents. The studycouldnotbemore timely.Medianhousehold income in theUnitedStateshasbeenstagnant for2decades, aperiodwhenwealth shifteddramatically to theupper class.7Wideningincomeinequalityandtheendangeredmiddleclassarenow topics of public discourse.Meanwhile, thepublic health literaturehasdocumentedasteepeninghealthgradientbasedonsocioeconomic status.8 The adverse consequences of having low educationandincomehaveintensified.5Lifeexpectancyhasdecreased forwhitesof lowsocioeconomic status.9,10Chettyet al confirmthisdisturbingpattern,reportingthatthehighest-income quartile enjoyed the greatest gains in life expectancy between 2001and2014,whilethelowest-incomequartilesawsmallgains in lifeexpectancy.Theyreported that lifeexpectancy increased by2.3years formenand2.9years forwomeninthetop5%ofthe incomedistributionbut increasedbyonly0.3years formenand 0.04 years for women in the bottom 5%. Life expectancy decreasedincertainstatesandcities.Thehealthimplicationsofthis trend are concerning, especially at a timewhen the number of financially stressed households is increasing. Opportunity—the chance to thrive in health and other aspirations—is unevenly distributed across society. Due to structural changes in theeconomyand the legacyofbiasedpolicies, the poor and people of color face greater barriers to education and economic opportunity. Racial disparities in income are dwarfed by disparities inwealth (eg, assets, net worth), which may be an even stronger health determinant. The networth of whites is more than 15 times that of blacks ($111 740 vs $7113) and more than 13 times that of Hispanics.11 Health is shaped not only by household finances but also by neighborhood Editorials pages 1703 and 1709