Politics & Policy

Race, Class, and Health in the 21st Century

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From the December 21, 2015, issue of NR

U.S. health progress is badly faltering because of racial, social, and economic disparities, according to many public-health specialists, both in the academy and in Washington, D.C. Proponents of this view typically favor major government interventions to reduce these disparities.

If the politically correct narrative truly reflected our modern-day realities, America’s “whites” would generally enjoy better health than our “people of color,” and more-affluent groups would always enjoy better health than more socioeconomically disadvantaged strata. But none of that happens to be true.

The fact of the matter is that socioeconomic disparities are just not that good in predicting health disparities. In fact, it is commonplace today for poorer, less educated groups to enjoy substantially better health than those who enjoy distinctly greater socioeconomic advantages. The surprising — but also encouraging — fact is that groups suffering purported social disadvantage can achieve excellent health outcomes in America today.

To lay out the complex story of race, class, and health in modern America, we need to begin at the beginning: the overall post-war record for health progress. There is no sugarcoating the basic facts: U.S. results over the past half century could most charitably be described as mediocre. While America has achieved continuing incremental improvements in overall health conditions, progress has been markedly slower than in other affluent Western democracies — and our ranking in this roster has steadily declined.

In its most recent assessment, the OECD (Organization for Economic Cooperation and Development, an association composed mainly of aid-dispensing Western democracies) placed U.S. life expectancy at birth 25th among its 34 members — tied with Chile, and ahead only of Turkey, Mexico, and a handful of former Soviet-bloc countries. And from 1983 to 2008, according to the OECD, America’s life-expectancy progress was the weakest of any member state. So poor is American long-term health progress that the present-day region of Europe once known as East Germany has overtaken us in life expectancy, according to the Human Mortality Database.

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What accounts for this woeful situation? Over the past half century, America has become increasingly multiethnic. Some might be tempted to attribute America’s decline in international health rankings to the rise of its minority populations. The facts, however, speak otherwise. The Social Science Research Center’s “Measure of America” project has calculated life expectancy by ethnicity for the United States, and the ranking of non-Hispanic white America within the OECD would be almost exactly as disappointing.

The troubling tale of health in white America was depicted in electrifying detail just last month by Anne Case and Angus Deaton, this year’s Nobel laureate in economics. By their reckoning, mortality levels for middle-aged Anglos, or non-Hispanic whites, worsened between 1999 and 2013, owing largely to an upsurge in deaths from cirrhosis, suicide, and drug-related poisonings among those with no more than a high-school education. Whatever else may be said of these tragic findings, they are not exactly a case study in white privilege.

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The Case and Deaton paper on recent mortality trends for non-Hispanic whites ages 45–54 underscores just how much socioeconomic status can matter to health for certain groups at certain times and under certain circumstances. To be clear: There is no gainsaying the general insight that more-prosperous and better-educated people can 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 offer us all that much help in understanding the big health differentials we see in our society today. We can make the point by contrasting the figures for age-standardized mortality with indices of socioeconomic disparity among America’s major ethnic groups. (See the accompanying table.)

Consider first what this table reveals for the Anglo population in contemporary America. By all the indicators in this table — poverty rates, education, income distribution, access to health insurance, use of health services in the past twelve months — the Anglos appear to be decidedly better off on average than Americans as a whole. But age-standardized mortality for Anglos was slightly worse than for the nation as a whole around 2010.

Consider next the circumstances for our Asian minority (officially, Asian and Pacific Islanders). On all of the social and economic indicators in the table, the Asian-American population fares less favorably than the Anglos. Yet age-standardized mortality levels for the Asian-Pacific population are officially estimated to be 40 percent below the national average.

Finally, consider the Hispanic-origin population. By a number of measures, it looks to be the most socioeconomically disadvantaged major ethnic group in America today. Nearly 40 percent of Hispanic-American adults, for example, have no high-school degree (2009); over 30 percent 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 25 percent lower than the average for the nation as a whole.

#share#Thus the politically incorrect paradox of health in modern America: Minority groups reporting more poverty and income inequality, lower educational attainment, less health-insurance coverage, and greater likelihood of no professional medical treatment than the Anglo majority also report significantly lower mortality (and therefore longer life expectancy) than do Anglos and Americans on the whole. And this paradox is not new. Mortality rates for America’s Asian and Hispanic minorities have been better than those of non-Hispanic whites for many decades — in fact, for as long as such numbers have been compiled. To be sure, today as in decades past, non-Hispanic blacks have a poorer health profile than do Anglos, but African Americans now account for only about a third of the country’s non-white population.

The phenomenon of superior health performance by ostensibly disadvantaged minorities can be seen from sea to shining sea. In Los Angeles County, Hispanics and Asians both report higher poverty rates than do Anglos (the rate for Latinos was more than double that for non-Hispanic whites), and yet their life expectancies were also significantly greater: by 2.4 years among Hispanics, and by five years among Asians.

In New York City, whose Hispanic population differs substantially from that of Los Angeles County by country of origin, Hispanics again edge out Anglos in life expectancy, as they have been doing for many years, even though their poverty rate in New York in 2010 was more than double that of non-Hispanic whites.

The phenomenon of superior health performance by ostensibly disadvantaged minorities can be seen from sea to shining sea.

The tantalizingly tenuous relationship between poverty and health outcomes in New York was further underscored by the New York City Department of Health in a 2010 analysis of life expectancy, ethnicity, and neighborhoods. It is true that the lowest life expectancy is recorded for blacks who live in the city’s poorest neighborhoods and that life expectancy tends to be commensurate with the affluence of the neighborhoods in which New Yorkers live. But life expectancy for blacks in the city’s most affluent neighborhoods was notably lower than for Hispanics in the city’s poorest neighborhoods. And there is no “poverty neighborhood” effect at all for New York’s Asian population. Indeed, Asians who live in New York’s poorest neighborhoods enjoy life expectancies roughly five years higher than do whites in the wealthiest neighborhoods.

Let us return to our international ranking of health performance. America’s standing depends on which group and region we are talking about. For African Americans, overall the story is pretty dispiriting. Life expectancy for non-Hispanic blacks in 2007 was lower than that of all but three of the OECD’s 34 countries. Even in Rhode Island, the state where black life expectancy was highest, it nevertheless ranked lower than the averages in 20 OECD countries. For U.S. whites, the situation looks better, though only to a degree.

But when we place Hispanic Americans’ health in international perspective, the contrast is dramatic. According to the calculations of the Measure of America project, Hispanic Americans enjoy a life expectancy higher than that of any OECD country, even Japan, the organization’s healthiest population. And America’s Asian population is almost off the chart. By these same estimates, Asian Americans can expect to live about five years longer than Japanese citizens.

In other words, if the United States were a nation composed solely of its Hispanic and Asian-Pacific minorities, we would be the healthiest country on earth — even though our country would also have higher poverty rates and greater economic inequality than it does today.

#related#If we are to improve our country’s public-health conditions, we should try to understand what is going right in those populations, all socioeconomic disadvantages notwithstanding. Are such superior health outcomes due to behavior? To lifestyles? To outlook and attitudes? To the disproportionate representation of immigrants among them? To some combination of these things?

We should desperately want to know the answers. But apparently not everybody is in a hurry to find them. These stunning achievements in life expectancy have been greeted with an almost equally stunning incuriosity by a great many in the public-health community. Remarkably little research is currently under way on the determinants — or potential replicability — of these success stories in U.S. health.

The first step toward better health for Americans must be better questions about how public health really works, and why. For the purpose of that inquiry, today’s fashionable “social justice” nostrums are not only naïve but useless.

— Nicholas Eberstadt holds the Henry Wendt Chair in Political Economy at the American Enterprise Institute. This article originally appeared in the December 21, 2015, issue of National Review.

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Nicholas Eberstadt — Mr. Eberstadt holds the Wendt Chair in Political Economy at the American Enterprise Institute and is a founding director of HRNK, the U.S. Committee on Human Rights in North Korea.

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