For the first time in U.S. history, the leading association of psychiatrists has condemned a tax bill.
They are not alone among doctors. In a joint statement this month, the American Psychiatric Association, American College of Physicians, American Congress of Obstetricians and Gynecologists, and American Academy of Pediatrics, among others, voiced stern opposition to the Republican tax proposal.
Their main concern is insurance. The repeal of the Affordable Care Act’s individual mandate—a provision rolled into the Republican tax bill—means millions more people will be uninsured by 2027, according to the Congressional Budget Office (CBO). Individual and small-group marketplaces will be destabilized, and rates of medical bankruptcy will return to pre-Obamacare levels.
This all sounds bleak. Typically people heed the warnings of their doctors. Americans now have warnings from groups that collectively represent more than 560,000 doctors. Still, I think these groups are missing the full breadth and depth of the bleakness.
These doctors focus on the loss of health insurance, in part because they have financial stakes in people having health insurance, and in the medical establishment including as many people as possible. Though they write that having health insurance “is the gateway to prevention and wellness,” seeing a physician is a small part of prevention and wellness. There are serious limits to what can be accomplished in a 10-minute conversation every year.
The collapse of the health-insurance market, while important, is far from the only way in which this tax bill relates to health. Most of what makes people healthy or unhealthy is the result of our day-to-day activities in our day-to-day environments, and what sort of stress we incur. By focusing on health insurance, these groups overlook the more insidious threat to health in this bill: the health effects of income inequality.
Barbara Wolfe, a professor of population-health sciences at the University of Wisconsin, explained to me that this is what economists call an income-inequality hypothesis: Your health is influenced not only by your own level of income, but by the level of inequality where you live. Sociologists have described a similar socioeconomic-inequality hypothesis: As socioeconomic disparities grow, overall health metrics decline.
Health effects of income inequality seem to act through social capital, a broad term that includes neighborhood cohesion, close friends, and emotional support from family. These things mitigate some negative health effects of poverty. The sociologist Robert Putnam famously advocated for revival of social capital primarily through civic engagement. Though, of course, the willingness and ability to engage depend on more than an individual’s own motivation, but on, in a circular way, existing social capital. It’s a thing that can build on itself and grow exponentially. Or it can collapse.
While a lot of research has focused on the health effects of poverty, the effects of income segregation are increasingly relevant, as most wealthy countries are seeing growing divides. In the United States, 1 percent of Americans control some 20 percent of the income (the percentage having doubled since 1980). Between 1970 and 2007, the proportion of families in metropolitan areas living in middle-class neighborhoods declined by a third. Wealth engulfed the middle ground.
According to a CBO report released Sunday, the current Senate bill only stands to exacerbate that concentration. Over the coming decade, Americans making between $40,000 and $50,000 will pay $5.3 billion more in taxes than they currently would. Meanwhile, those who make $1 million or more would pay $5.8 billion less.
In the short term, some middle-class families will receive several hundred extra dollars per year. As Paul Ryan tweeted earlier this month, “Meet Cindy: a single mom, making $30,000 per year, who hopes to one day get beyond living paycheck to paycheck. With a $700 increase in her tax refund each year under our tax bill, Cindy can start saving for her future.”
That comes out to $13.46 per week. While it’s not necessarily an inconsequential amount if all other things remain the same, the much larger tax cuts for the wealthy mean Cindy will be living with even less relative to the people who define wealth. The chance that she or her child can “climb” to that point diminishes.
Though it has been long known that poverty is a risk factor for many diseases and premature death, there is also evidence that this “relative deprivation” is consequential to health in ways just beginning to be understood. “The broader observation is that income inequality itself leads to poorer health,” said Wolfe, noting that this has implications for the wealthy and middle-class as well. “We might expect that those at the bottom would be worse off, but evidence suggests it is also bad for high-income residents.”
Ichiro Kawachi, a professor of epidemiology at Harvard University, has been a leading voice in calling attention to the health effects of income inequality. He has posited that social cohesion is eroded by a “pollution effect”: Wealth is sucked into private enclaves, gated subdivisions and neighborhoods where the 1 percent buy out of the health-care system and have less reason to interact with or care about the other 99.
At the same time, it is becoming increasingly clear that most diseases are affected, if not caused, by stress. Psychosocial circumstances modulate everything from blood pressure to immune functioning to sleep. The major stressors across American society bear on finances. The effects of social immobility are made worse with greater income segregation; the apparent ladder that seemed impossible to climb just keeps getting longer.
“Income inequality has pathways through which it can impact health, no question about it,” said Subu Subramanian, a professor of population health and geography at Harvard. “The concern for a society like the United States is more in relation to relative deprivation—in addition to absolute deprivation. Whether it’s through increasing premiums, or shrinking investment in the community, or disenfranchisement or displacement.”
The idea is that once some basic needs are met, the visceral effects of being non-wealthy don’t deal much in absolute numbers. Wealth matters to health in that it informs perceptions of ourselves, and our sense of growth and mobility. Known as John Henryism, it is well documented that when we strive against stacked odds, we pay with our health.
“It’s not really ‘Does that person have nicer shoes than I do?’ stuff,” said Subramanian. “It’s the big-ticket sense of place and value: Which neighborhood can I afford to belong to, and so what sort of life can I provide for my family?”
In that sense, he said the “I don’t have very much” phenomenon is now kicking in even among the upper-middle class, in the $80,000 to $100,000 income range. This includes people who can afford to live in big cities, like New York or San Francisco, but for whom there are clear lines as to which neighborhood they can afford.
The pace at which gentrification and income segregation are happening mean there are places where people making that much will be priced out and have to move, and even though they are far from poverty, they experience relative deprivation. Most people are fine if they don’t have the nicest house on the block, or if they don’t live in their ideal neighborhood. But as soon as it becomes impossible to live in that neighborhood at all, and large swaths of major cities are simply out of the question, the social fabric is torn, social capital collapses.
“If you have to live an hour away from what you consider home, and where friends and family are, and you feel out of place or relatively deprived, that will have a real effect,” said Subramanian. This is abetted by uncertainty about whether one’s kids will be able to do “better” than they did, and whether parents can provide that opportunity if they can’t live in the district that they believe would afford that opportunity. It can mean leaving behind friends and family, forgoing a better school system—or trying to make it work by taking on more debt, living above one’s means, and so then worrying more about career and less about a healthy, active, social life.
In that milieu, without an individual mandate, it may seem reasonable or even necessary to put that money toward a bigger mortgage instead of saving it or buying insurance. All of this does not paint a picture of thriving.
The doctors who came closest to expressing this were at the Association of American Medical Colleges, who said in two statements that the organization is “deeply disappointed that Senate Republican leadership has decided to put the health and well-being of millions of Americans at risk,” and that the legislation “would have a damaging impact on the nation’s medical schools and teaching hospitals, and on the patients we care for, the students and residents we teach and train, and the millions of Americans who gain hope from the research we conduct.”
Finally, if all of this is not sufficiently bleak, there is also the fact that the bill lowers taxes on alcohol. Alcoholism is the country’s third leading cause of preventable death. While the remaining middle class is increasingly likely to feel trapped and disenfranchised, and declining social capital leads to resentment and isolation, and lack of access to affordable health care means more self-medication, there will be cheap alcohol.