mortality benefits from decreasing wealth inequity in the US

 A recent analysis found that wealth redistribution to decrease inequities in the United States would be predicted to lead to both substantial reductions in social inequities together with population longevity, similar to other high income countries in the world (see income inequality dec life expectancy JAMAIntMed2024 in dropbox or doi:10.1001/jamainternmed.2023.7975)

 

Details:

-- 35,164 participants were evaluated with data on wealth and longevity from the Health and Retirement Study (1992-2018), a study of community-dwelling individuals >50yo, assessing the difference between personal wealth and their death rates. Death rates were adjudicated through the National Death Index

    -- the HRS involved interviews in 14 biennial waves

    -- the researchers chose to assess deciles of wealth given the nonlinear pattern of wealth differences in the US (see below for details of the dramatic inequities within the US)

    -- wealth was assessed by the array of financial inputs minus debts (see below for more info on this)

    -- researchers chose to assess the initial wealth decile as their baseline “since prospective studies suggest that poor health predicts the subsequent acquisition of medical debt”

-- mean age 59, 50% female, Black 11.6%/Latinx 9%/white 75%

    -- all of the following comparisons between those in the highest few deciles versus those in the lowest few deciles of per-capita wealth were significantly different, with p<0.001:

        -- being white vs Black or Latinx, being female, being married or partnered at study entry, higher education level, and higher household income

 

--Main outcomes: estimates of the association between per-person wealth decile (ie household wealth divided by the number persons in the house) and survival (adjusted for age, sex, marital status, household size, and race and ethnicity), as well as predicted differences in longevity that might occur using different wealth distributions. In particular, they assessed:

    -- a simulated model based on an equitable distribution of wealth (all patients having a wealth of $281,767)

    -- a simulated model based on a minimum inheritance for all of $169,060

    -- a simulated wealth distribution similar to Japan’s, where 58.6% of the national wealth was held by those in the highest wealth decile (versus 70.7% in the US). This study chose Japan as the comparator since it has the most equitable wealth distribution per the OECD, the Organization for Economic Cooperation and Development

    -- a simulated baby bond approach (similar to one proposed by US representative Ayanna Presley and Sen. Cory Booker: all newborns would receive a $1000 deposit in an interest-bearing accounts with further deposits of up to $2000 a year based on the household income to poverty ratio

 

Results:

-- the deciles of per-capita wealth varied pretty dramatically per decile:

    -- decile 1: <$1

    -- decile 2: $1-$6163

    -- decile 3: $6164-$22,369

    -- decile 4: $22,370-$43,862

    -- decile 5: $43,863-$70,698

    -- decile 6: $70,699-$106,692

    -- decile 7: $106,693-$161,690

    -- decile 8: $161,691-$248,882

    -- decile 9: $248,883-$469,460

    -- decile 10: >$469,461

 

--adjusted mortality, in their most adjusted mode that, included demographic variables, education, income, and wealth:

    -- male: 62% increased risk, HR 1.62 (1.56-1.67)

    -- married or partnered: 7% decreased risk, HR 0.93 (0.88-0.97)

    -- number of household residents: 4% decreased risk, HR 0.96 (0.94-0.98)

    -- race/ethnicity: Black non-Hispanic, not statistically significant; Latinx 41% decreased risk, HR 0.59 (0.54- 0.63)

        --it was notable that there was a progressive decrease in mortality with their adjusted models (i.e., moving from model one with only demographic variables, then adding education, or adding income, or adding wealth found that each improved the adjusted mortality risk for those in the lower wealth deciles, and the combination of all of these in the final adjusted model was the best. This means that at least a lot of the differences in mortality could be explained statistically by controlling for these confounders)

 

-- death rate comparing those with the highest versus lowest decile in the US:

    -- 41% lower in the highest wealth decile, HR 0.59 (0.53-0.66)

    -- this difference represents a 13.5 year difference in survival

 

--simulating perfect equality in the wealth distribution (with everyone having an equal $281,767 in wealth):

    -- increase of 8.8 years of longevity in decile one, with population-wide median longevity increase of 2.2 years (which fully closes the mortality gap between the US and the OECD average)

-- simulating minimum inheritance proposal alone ($169,060): 

    – increase of 8.2 years of longevity in decile one, with population-wide median longevity increase of 1.7 years

-- simulating wealth distribution similar to Japan’s: 

    – increase in 5.3 years of longevity in decile one, with population-wide median longevity increase of 1.2 years

-- simulating baby bonds proposal as per above:

     -- increase in 6.4 years of longevity in decile one, with population-wide median longevity increase of 1.0 years

  

Commentary:

-- income inequality has been known for many decades to lead to adverse health events, including higher mortality. The UK has been in the forefront of many studies on income inequality, as well as stress levels and the associated increased mortality. There were studies done by Jenkins, I believe in the 1960s (as in: prior to the Internet as we know it, and unfindable at this point), looking specifically at the South End in Boston, documenting increased mortality in what was then a low income district

-- wealth inequality is more difficult to measure than income inequality, but it is a more reliable social economic variable, since it includes other important aspects of wealth (eg investments, generational wealth handed down in the family), financial security overall (ie, the ability to survive employment changes), is more stable over time, and is associated with better access to critical resources (e.g. health and education)

    -- the measurement of wealth includes such assets as residences and other real estate, vehicles, businesses, investments (stock/mutual funds/bank accounts/retirement accounts/bonds/etc.) but also includes debts (e.g. mortgages/home loans/credit card or medical debt/etc.)

-- and, wealth inequality is more profound in the US than in other similar countries, per OECD

    -- in 2019 in the US, the wealthiest 10% held 72% of total wealth, and families in the top 1% held more than one-third of the total wealth. The poorest 50% had only 2% of the wealth (https://www.cbo.gov/publication/58533 )

    -- “Household net wealth was most unequally distributed in the United States, where the wealthiest 10% of households owned close to 80% of total wealth. The concentration at the top was also high (top-10%-shares above 55%) in Austria, Chile, Estonia, Denmark, Germany and the Netherlands”, per https://www.oecd.org/wise/Inequalities-in-Household-Wealth-and-Financial-Insecurity-of-Households-Policy-Brief-July-2021.pdf )

-- But, life expectancy at birth is 2.1 years shorter in the US than the OECD average, with notable differences in infant mortality, self-rated health, and income-based disparities in access to care (https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2023.307310 )

 

-- This study had several very notable conclusions:

    -- the wealth distribution of participants at least 50 years old living in the community is strikingly nonlinear. It is literally shocking that 10% of this population in the HRS survey had <$1 in per-capita wealth, and 20% had <$6164 (and for many people, the minimal social security check, if available, does not provide a livable income)

    -- it was evident that several of the specific wealth-associated factors (education, income) did explain much of the variation in mortality, suggesting that great improvements in these factors would likely help a lot

    -- an equitable distribution of wealth in the US would likely improve mortality rates in the US to the average for OECD countries

    – it is important to include more than income inequality in our conception and analysis of social inequality, since other factors are really important (eg, inheriting a huge amount of money does provide much security and resilience in times of distress. And the amount of accumulated wealth that can be inherited by family members is remarkably paltry in the poorer neighborhoods)

 

Limitations:

-- it should be noted that the country comparisons with the US were with the OECD average, and the richest country in the world (i.e. the US) should be able to achieve more than that

-- it is notable in this study that they controlled only for certain demographic variables, but this provides an incomplete picture of the societal effects that wealth confers to individuals, for example:

    -- Stress has been shown in many studies to be a predictor of many adverse health events, including mortality.

    -- A recent study found that mental stress was a significant predictor of cardiovascular morbidity and mortality:  https://gmodestmedblogs.blogspot.com/2022/01/stress-induced-cardiovascular-disease.html

    -- studies have also found that there is considerable variability in how individuals respond to stress, some finding that the same objective stress is subjectively much more stressful for some people than others. Several studies have also shown that those people with better social support networks tend to have a lower perception and internalization of objective stressors

    -- for example, studies have found that people living in the same neighborhoods may well have very different perceptions of stress pertaining to the quality of their neighborhoods (e.g. how safe they are, or how happy they are to live in that neighborhood)

    -- but, this current data-based study does not have the granularity of individual-level data about perceived stress and therefore cannot fully represent the extreme differences between the wealthiest and poorest.

-- and there are lots more inequities not measured in the HRS data base, such as air quality (inner city housing vs lots of land in wealthy suburbs), environmental exposures including air pollution, occupational exposures, access to healthy foods and exercise venues, etc. And all of these affect both the quality and quantity of life

-- One issue with the mortality assessment by adjusting for education, income, wealth, and the combination is that there was a huge difference in the numbers of people in the lower vs higher wealth deciles. For example, there were only 104 Black non-Hispanic and 89 Latinx individuals in the highest decile (vs 2691 white individuals). And, even in decile 6, there were only 514 Black non-Hispanic and 253 Latinx individuals (vs 2626 white individuals). This distorted distribution does challenge the validity of their results, and emphasizes the importance of other potential confounding factors (such as the role of perceived life stressors), or even the magnitude of the effects of structural racism on people’s lives, may play an important role in the mortality outcome (this is not to imply that wealthy people-of-color do not experience structural racism or feel more stressed than their wealthy white peers, just that the levels of their stress overall are likely lower than for those with very low levels of wealth)

 

so,

-- an important article quantifying the effects of wealth disparities on life expectancy

-- and, through mathematical modeling, this study suggested that decreases in these disparities would likely be associated with pretty dramatic improvements in longevity, with a 5.3 year increase in those in the poorest wealth decile by enacting the Japanese approach, or an 8.2 year increase by having a minimum inheritance for all (as opposed to the current system where the obscenely wealthy pay lower taxes and work out methods to dramatically decrease inheritance taxes vs what the average workers can do)

-- it seems that there is really a public health imperative (and overall social one) to improve the wealth gap in the US, where 10% of the population >50yo seems to have a total wealth of <$1....

 

geoff

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