The Politics of Health Inequality

The eight major Democratic candidates for president all agree that Americans need expanded and more affordable healthcare. From Medicare For All to expanding the Affordable Care Act to tweaking public insurance options while maintaining private coverage, each candidate contends their vision will make healthcare more equitable.

But according to Julia Lynch, Associate Professor of Political Science, none of those plans will solve the problem of heath inequality in the United States.

In her new book, Regimes of Inequality: The Political Economy of Health and Wealth, Lynch outlines what her decade of research on the topic in England, Finland, and France has revealed: health outcomes are directly linked to social and economic inequalities, and the way politicians frame the problem of health inequality sets it up to be unsolvable.

“Politicians usually talk about health inequalities because they want to avoid talking about other, deeper inequalities,” Lynch says. “They’re politically scary.”

On Super Tuesday, when 14 states hold primaries that will allocate a third of all delegates, Lynch outlines five things voters should know about health inequality.

Giving everyone access to affordable healthcare will not make everyone equally healthy.

People think healthcare must be the solution to health inequalities, but healthcare can only make you better once you’re already sick. Health inequalities arise because poorer people, people who are exposed to everyday racism, people who are exposed to the slings and arrows of unequal societies in a variety of ways, get sick more often.

It’s true that it is especially bad if you’re getting sick more often and don’t have access to healthcare, but having access to healthcare isn’t going to stop you from getting sick to begin with.

Even focusing on a really expansive view of what we could do for healthcare, like Medicare For All, isn’t going to solve the problem of inequality. That doesn’t mean providing universal health care is not a good thing to do, but it’s not going to solve the problem of health inequalities.

Politicians talk about health inequalities because they’re afraid to talk about the underlying socioeconomic inequalities that generate them.

A lot of politicians don’t really understand what causes health inequality, so they say, “give everyone healthcare!” Others understand that there is a deeper connection between income inequality and health inequality, but they don’t fully appreciate that you can’t solve the health inequality problem without going upstream and solving the income inequality problem.

Politicians may feel that it’s too politically dangerous to talk about trying to solve the deeper, underlying problems of inequality in power and resources, so they reframe inequality as a matter of health, which seems easier to tackle. But a key finding of the book is that that reframing actually makes the problem of inequality harder to solve, not easier.

When politicians in Europe talk about health inequalities it’s very often because they are afraid to talk about deeper inequalities like inequalities in income and in educational opportunities.

In the U.S., racial inequality is a huge problem and independent of income and education. Highly educated, upper middle-class Blacks in the U.S. have worse health outcomes than poorer whites, because they have to live with racism.

Trying to solve the problem of health inequalities by acting on the social determinants of health sounds like a good idea, but it usually doesn’t work.

Some candidates understand that health care alone isn’t enough to solve the problem of health inequality.  For example, Pete Buttigieg’s health plan emphasizes working to reduce inequalities in the social determinants of health.  These are things that are related to power and resources and that affect health—like housing, environment, nutrition.  But what they don’t appreciate is that income, educational, and racial inequalities are what social epidemiologists call “fundamental causes” of health inequalities. What that means is that these deep social inequalities are linked to many different health outcomes through many different pathways.

That means that you could interrupt the pathway between income and health by giving everyone access to sanitation, for example. Great, we did that, and that means poor people aren’t dying from cholera in the U.S. But guess what? In the United States, these things aren’t really what kill most people. Poverty and inequality in the U.S. means that people are dying of cardiovascular disease from stress and poor nutrition, not from microbial contamination of water. Because there are multiple pathways linking unequal resources and health, that fundamental causal relationship between income inequality and health inequality is always going to exist until you get rid of the underlying inequality.

There are lots of social determinants of health and unless you get all of them, health inequalities are going to persist.

Another reason that working to reduce inequalities in the social determinants of health often doesn’t end up reducing health inequalities is that the way that governments have tried to do this is through big attempts to do coordinated, cross-sectoral policy making, which is really hard to get right.

The idea is you get people working across different government departments, like health and human services and transportation, all of which we know are social determinants of health. You have to get everybody working together to try to solve the problem of health inequalities and this is incredibly complicated. Even governments that have very strong bureaucracies and a really strong commitment to equality couldn’t get it done. Examples I give in the book like the United Kingdom under the Blair government and Finland in the 2000s really tried to address the problem of health inequalities through this cross-sectoral “Health in All Policies” policymaking strategy, and even for them it was too complicated.

The irony is that if they had just decided to raise taxes and redistribute, they probably could have made a lot more progress.

Politicians reframe the problem of inequality because they’re afraid to talk about the old mechanisms for taxing and redistributing and regulating.

Politicians usually talk about health inequalities because they want to avoid talking about other, deeper inequalities, because these are politically scary. But from a technical, policy-making standpoint it’s much easier to just do the things that governments have always done: tax and redistribute, regulate products and service and labor markets, spend public money on stuff.

I talk about taboos in the book and the reason I use the word taboo is that’s the word that these policy makers used. It was so interesting that in all three of these countries the politicians and policy makers talked about these taboos against talking about the old policies they used to use to keep inequality under control.

What I argue in the book is what becomes taboo depends on the shape of the welfare state that was built in the 1950s and the 1960s.

You’ve got three types of welfare states that develop in post-war Europe, and then in the 1990s there is a wave of neoliberal, competitiveness-oriented policy ideas that interact with different types of welfare states in different ways, and that causes different things to become taboo in different places.

What becomes taboo in each welfare state type is the central mechanism that policy makers used to use to contain inequality. In the smaller, “Liberal” welfare states like the U.S. or the U.K., that’s taxing and redistributing. In the continental European countries, that tends to be public spending, and in the Nordic, Social Democratic countries it’s a combination of taxing and redistributing and internal regulation of markets.

For a variety of reasons these things become much scarier for politicians to do in the 1990s under neoliberalism, and that’s what generates the taboos.

When politicians are straight with voters about what inequality really is and what it takes to solve the problem, voters seem to respond.

I think it’s possible that inequality has become so severe, particularly in countries like the U.S. and the U.K., that we are starting to see politicians who are really willing to bite the bullet and say, “We really mean it this time. We actually want to reduce inequality.”

Politicians have had these self-imposed taboos and now that some of them are starting to lift those taboos, they’re seeing that they can actually get the support of voters.

I think both Bernie Sanders and Elizabeth Warren have in different ways harnessed that energy around saying, “Look, let’s tell it like it is. We are not going to solve the problems in this country by tweaks around the margins. It’s going to take actual, fundamental state action to get this done.”

I think my advice to politicians would be don’t try to get fancy about what inequality is, and don’t try to get fancy about the policy tools that you use to try to solve the problem. Just do the stuff that we know works.

As the last paragraph in my book reads: “It will require some boldness to break with so many years of taboo, but politicians should take heart in the knowledge that the public, the pontiff, and the IMF all agree that inequality needs to be brought to heel. And if Brexit, the resurgence of reactionary right-wing nationalist parties, and the election of Donald Trump have taught us anything, it is that taboos can be broken.”

Lynch is speaking about her book on tours at Boston University, Yale University, Bentley University, Stanford University, Colby College, London School of Economics, Max Planck Institute for the Study of Society, European University Institute, and the University of Newcastle.

Lynch will speak about the book on podcasts and radio shows including: The Week in Health Law, Wharton Business Daily on Sirius XM Business Radio, Rhodes Center Podcast on Economic Ideas and Real Politics.

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