“Introduction
During the last half of the 2010s, life expectancy for college-educated persons continued to increase, while life expectancy for adults without a college education decreased. This crisis in the health of adults who do not have a college degree rose to national attention due largely to the opioid crisis. Initially, the opioid crisis devastated predominantly White communities in the midwestern and north-central states of the US, but eventually spread to other communities and currently disproportionately affects Black and Latino populations. However, a closer analysis reveals that mortality rates for adults who were not college-educated increased for many causes of death, not just drug- and alcohol-related deaths. Moreover, this trend in life expectancy predates the COVID-19 pandemic, but has been further exacerbated by the overall decline in life expectancy attributable to the novel virus. [..]
The current study reports the economic burden of health inequities at the national and state levels for 5 racial and ethnic minority population groups (American Indian or Alaska Native, Asian, Black or African American [hereafter referred to as Black], Hispanic or Latino [hereafter referred to as Latino], and Native Hawaiian or Other Pacific Islander; the term non-Hispanic for the racial groups was dropped for ease of exposition) and for 3 education groups (adults with less than a high school education, those with high school degree or General Educational Development [GED] equivalency credit, and those with some college or an associate degree).
Methods
We defined health equity targets of reaching the 10th percentile of the predicted prevalence rates for 13 health conditions and the crude death rate for all-cause mortality [..]. The 13 health conditions include the following 10 Agency for Healthcare Research and Quality (AHRQ) priority health conditions: hypertension, high cholesterol, diabetes, coronary heart disease/angina, myocardial infarction/heart attack, stroke, asthma, emphysema/chronic bronchitis, joint pain/arthritis, and cancer. [..]
The following 4 databases were used for data collection: the 2016-2019 Medical Expenditure Panel Survey (MEPS), state-level 2016-2019 Behavioral Risk Factor Surveillance System (BRFSS), 2016-2018 mortality data from the National Vital Statistics System (NVSS), and 2018 IPUMS American Community Survey. [..]
Results
In 2018, the overall economic burden of failing to achieve the health equity goals was $1.03 trillion. This included $421.1 billion for racial and ethnic minorities and $608.7 billion for the White population. For racial and ethnic minorities, approximately two-thirds of the economic burden was attributable to premature death, while excess medical care cost was 18% of the total cost and lost labor market productivity was 14%. Excess premature death contributed to more than half of the economic burden for the White population. [..]
Most of the economic burden of racial and ethnic health inequities was borne to the Black population (74% [MEPS] or 68.7% [BRFSS]), followed by the Latino population (13.5% or 20.9%), the American Indian or Alaska Native population (6.5% or 5.8%), the Native Hawaiian and Other Pacific Islander population (4.6% or 2.7%), and the Asian population (1.4% or 1.9%). For each group, their share of the economic burden was disproportionately greater than their share of the non-White population, except for the Asian population. For American Indian or Alaska Native, Black, and Native Hawaiian and Other Pacific Islander populations, most of the economic burden of health inequity was due to premature deaths. For Asian and Latino populations, the bulk of the burden was due to excess medical care costs. [..]
In 2018, the overall economic burden for failing to reach the health equity goals was $975.7 billion for adults 25 years and older. This included $940.4 billion for adults 25 years and older with less than a 4-year college degree and $35.3 billion for adults 25 years and older with a 4-year college degree or more. Notably, adults with a 4-year college degree had zero premature death costs. The crude mortality rates for college-educated adults in each age category were lower than the health equity target. Using the BRFSS prevalence data, the economic burden of education-related health inequities was $978 billion. Although the estimate based on the state-level BRFSS and NVSS data was $38 billion more than the estimates based on the national MEPS and NVSS data, the distributions for the burden by education group and category were similar. Approximately two-thirds of the economic burden was attributable to premature death, while excess medical care cost was approximately 15.8% of the economic burden and lost labor market productivity was approximately 17.8%. Most of the burden of education-related health inequity was incurred by adults with education at the high school/GED level, while adults with less than a high school education and adults with some college closely followed. A disproportionate share of the costs was associated with adults with less than a high school education. Although they make up only 9% of the individuals who did not complete 4-year college, they bore 26.2% of the costs. [..]
Relative to the size of the US economy, the economic burden of racial and ethnic health inequities was 2.2% of the gross domestic product (GDP). This is more than 76% of the 2018 annual growth rate of 2.9%. The economic burden of education-related health inequities was 4.7% of the 2018 US GDP, which is 1.61 times greater than the 2.9% annual rate of growth in the nation’s economy in the same year. [..] The economic burden of racial and ethnic health inequities ranged from 0.14% of the GDP in Vermont to 8.89% of the GDP in Mississippi. The economic burden of education-related health equities varied from 1.9% (District of Columbia) to 18.29% (South Carolina) of the GDP.
Discussion
[..] estimated that in 2018 the economic burden across all racial and ethnic groups was $1.03 trillion for excess morbidity and $975.7 billion for mortality for adults 25 years and older. This represents a significant amount of excess medical care spending and lost labor market productivity and the value of many lives lost to premature deaths. These results highlight the importance of making societal investments to improve population health to achieve aspirational health goals. However, we must ensure that efforts to reduce the burden of disease include racial and ethnic minority populations and persons with less than a 4-year college degrees because of social, economic, and political disadvantages they face. Investing in improving population health is likely to yield economic gains over time.
[..] The economic burden of health inequities will continue to increase if high mortality and morbidity in the growing racial and ethnic minority population and the decline in life expectancy for adults with less than a college education persist. In recent years, there have been numerous appeals to devote more resources to addressing health inequalities based on a compelling social justice argument. Addressing health inequities is “the right thing to do.” However, there is a compelling utilitarian argument as well. Health inequities are a significant drag on the economy and affect everyone. [..]
The economic burden of education-related health inequity impacted all racial and ethnic groups, including White individuals. In 2019, a total of 59.9% of White adults 25 years or older had not obtained a 4-year college degree. In comparison, 79.5% of American Indian and Alaska Native adults, 73.9% of Black adults, 81.2% of Latino adults, and 74.4% of Native Hawaiian and Other Pacific Islander adults 25 years or older had not obtained a 4-year degree. Only 41.9% of Asian adults 25 years or older had not obtained a 4-year college degree. Most of the burden of education-related health inequity was associated with White adults, because White individuals comprised 60.2% of the population without a 4-year college degree. The $335.4 billion premature death burden for the White population is probably due to adults who have less than a 4-year college degree. Importantly, the population with 4 years or more of college education had no excess premature death costs, thereby reinforcing the benefit of policies promoting college education.
The economic burden of education-related health inequity is more than double the economic burden of race and ethnicity health inequity in absolute terms. Only a portion of the costs of race and ethnicity health inequity is included in the economic burden of education-related health inequity. The economic burden for race and ethnicity health inequity includes the burden for all adults from underrepresented racial and ethnic groups, including adults with 4-year college degrees, adults between the ages of 18 to 24 years, and the premature deaths of children. But, it is important to acknowledge there are substantial race-based inequities in educational opportunity. As such, education is a key pathways through which racial and ethnic inequalities in health burden manifest. Racial and ethnic inequities in education originate from many historic and contemporary social issues, including structural racism and overt discrimination. Residential segregation (based on current and past housing discrimination) coupled with underfunding of schools in school districts with a primarily Black population is a major driver of educational inequities, as well as racial and ethnic differences in wealth. The dramatically lower wealth of Black families leaves parents unable to move into “good” school districts or to offer financial support to children pursuing higher education.
Conclusions
[..] Even a modest reduction in health inequities could potentially save the nation billions of dollars in medical spending and lost labor market productivity annually. As the nation progresses through the demographic transition and becomes a “majority-minority” population, even greater economic impacts are portended if health inequities are not addressed. Although it is impossible to put a precise monetary value on life, the loss of those who die prematurely has significant negative impacts on families and communities. Society expends significant resources on health care designed to keep people alive and, in this way, assigns value to loss of life. The economic burden of health inequity is affecting all individuals in the US. Prioritizing and implementing proven policies and practices that promote health equity would vastly improve quality of life at all levels of society.”
Full article, TA LaVeist, EJ Perez-Stable, P Richard et al., JAMA 2023.5.16