Health Policy

No, the Poor Don’t Always Have to Be With Us


OK, for you amateur (or professional) epidemiologists among us: what are the leading causes of death in the U.S.?  Let’s see, most of us would probably cite heart disease and cancer.  After that, we might guess smoking, obesity, or, in recent years, COVID.  But a new study has a surprising contender: poverty.   

It’s the kind of thing you might expect to find in developing countries, not in the world’s leading economy, the most prosperous country in the world. But amidst all that prosperity, the U.S. has the highest rates of poverty among developed countries, which accounts in no small part for our miserable health outcomes.  The new data on poverty’s mortality should come as no surprise.

The study, by University of California Riverside professor David Brady, along with Professors Ulrich Kohler and Hui Zheng, estimated that persistent poverty – 10 consecutive years of uninterrupted poverty – was the fourth leading cause of death, accounting for some 295,000 deaths (in 2019). Even a single year of poverty was deadly, accounting for 183,000 deaths.  

“Poverty kills as much as dementia, accidents, stroke, Alzheimer’s, and diabetes,” said Professor Brady. “Poverty silently killed 10 times as many people as all the homicides in 2019. And yet, homicide firearms and suicide get vastly more attention.” 

The study found that people living in poverty didn’t start showing increased mortality until in their 40’s, when the cumulative effects start catching up.  The authors note that these effects are not evenly distributed: “Because certain ethnic and racial minority groups are far more likely to be in poverty, our estimates can improve understanding of ethnic and racial inequalities in life expectancy.”

“We just let all these people die from poverty each year,” Dr. Brady told Oshan Jarow of Vox. “What motivated me to think about it in comparison to homicide or other causes of death in America is that people would have to agree that poverty is important if it’s actually associated with anywhere near this quantity of death.”  

Professor Brady believes: “We need a whole new scientific agenda on poverty and mortality.”  

Indeed, there is already an ”anti-poverty medicine” movement, founded by Lucy E. Marcil, MD, MPH.  “I started this work about a decade ago,” Dr. Marcil told Mr. Jarow. “At the time, there was a lot of confusion when I would say that I try to get more people tax credits because it helps their health. Now it’s pretty well established at most major academic medical centers that trying to alleviate economic inequities is an important part of trying to promote health.”

She further explained: “anti-poverty medicine is one step further upstream to the root cause. Social determinants of health are important, but getting someone access to a food pantry doesn’t really address why they’re hungry in the first place.”

But let’s be clear: while the healthcare system needs to recognize the burdens of poverty, poverty is not a problem that the healthcare system is going to solve.  “No country in the history of capitalist democracies has ever accomplished sustainably low poverty without an above-average welfare state,” Dr. Brady told Mr. Jarow. “And so until you get serious about expanding the welfare state in all its forms, you’re not serious about reducing poverty.”

“Welfare state” is not a term that goes over well in today’s political environment. The right wing despises it (and the people who might need it), and the left wing is struggling to make the case that “progressive” is not a four letter word.  Oh, we spend a lot of money subsidizing people, but most of it doesn’t go to poor people.  

We overwhelmingly support the federal dollars spent on Social Security and Medicare, even though neither is means-tested, but fewer recognize that things like the tax preference for employer health insurance and the tax deduction for home mortgage interest are hugely expensive – and go primarily to middle and upper income people.

We’d rather subsidize someone’s second or even third home than ensure poor people have adequate housing or enough food.  

Even the money we supposedly target for poor people doesn’t usually get to them. Dr. Marcil estimates only one-third of those eligible successfully navigate the bureaucratic gauntlet to claim the benefits. “In my experience,” Dr. Marcil said, “most social policies are written in ways that make it challenging for those who have been historically marginalized to access them.”

Similar, in his revelatory book Poverty, By America, sociologist Matthew Desmond points out that only a quarter of the families who qualify for Temporary Assistance for Needy Families (TANF) even apply for it, and, even worse, only 22% of money budgeted for TANF actually directly went to poor families.

The central point of Professor Desmond’s book is that we accept poverty in America because we – the non-poor — benefit from it. We like our tax preferences over directly helping poor people. We like to buy cheaper goods made possible because many employers don’t pay their employees a living wage. We don’t want affordable housing in our neighborhood because we fear it will hurt our property values. We don’t care if public school systems deteriorate as long as we can send our kids to private schools or move to even higher-income neighborhoods. And so on. It’s all about us.

As he quotes Tolstoy, “It is really so simple. If I want to aid the poor, that is, to help the poor not be poor, I ought to not make them poor.”

“If we had to boil it down to a single concept, we might just say that without poverty, we’d be more free,” Professor Desmond writes. “Why? Because poverty anywhere is a threat to prosperity everywhere.” 

He estimates that a measly $177b annually could help end poverty, and that this could be simply by letting that IRS go after tax avoiders.  Yet the right wing hates the IRS and has worked for years to ensure it can’t fulfill its mission of collecting the taxes that are owed. 

Professor Desmond coins the term “poverty abolition” and urges that we all become poverty abolitionists.  We give due credit to the 19th century abolitionists for helping bring about the end of slavery (even at the cost of a civil war), but somehow have relegated that kind of passion to history. But the 40 million Americans who live in poverty deserve better, as do the families of those 300,000 poor people who die every year. We may never cure cancer but we can end poverty.

Poverty, Professor Desmond reminds us, is a policy choice. If the poor are, as the saying goes, always with us, it is because we choose it.   

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented, and now regular THCB contributor

1 reply »

  1. So politicans and economists haven’t been able to solve this problem, but a bunch of health care providers turning their attention to poverty is just going to get us to the promised land of poverty abolition.

    Yes. Poverty is bad. Congratulations, what is J Random Doctor going to do about that?