Funding areas
economic Instability Impact on Health
We define economic stability as having essential resources for living healthy (e.g., income/expense, housing, education, etc). The CDC lists economic stability as a social determinant of health because of the access it provides to additional resources to improve individual health outcomes. Chronic conditions and premature deaths are most prevalent in populations that lack economic stability.
Inability to earn personal income contributes to the current worsening of economic stability was first accounted for the in the 1970s with the decline of workplace unions. Without the protection that unions provided to laborers, company investments shifted away from employee wages to limiting jobs, increasing automation production, and outsourcing work for less pay to foreign countries (Reich, 2013). This was done to increase higher profit for the company at the expense of Americans’ livelihood. With black Americans being excluded from these unions, this population remained unprotected from wage reduction and job losses. The trend of unemployment ranking then is as it is now. In 2021, the Bureau of Labor Statistics reports black Americans to have the highest unemployment rate compared to other racial and ethnic groups despite the recent increase in job availability (U.S. Bureau of Labor Statistics, 2021). Without personal income, generational wealth inheritance, affordable housing, and affordable education, black Americans experience the greatest economic instability which results in high levels of poverty seen in this population with one in every five black Americans living below the poverty line (U.S. Census Bureau, 2021). This directly impacts the condition in which blackAmericans are born, live, learn, work, play, worship, and age and impacts health and quality-of-life, substantially. Through the current administration’s efforts to Build Back Better some government-funded programs have increased substantially with intent to bridge the income gap through programs such as TemporaryAssistance for Needy Families (TANF), Earned Income Tax Credit (EITC) and Child Tax Credit (CTC), andSocial Security Insurance (SSI). However, for many, they are unable to access these resources or the assistance remains inadequate.
The Office of Family Assistance reported an average of 454 thousand adults and 1.6 million children who had received TANF cash assistance with approximately 25 million paid to recipients (Office of Family Assistance,2021). However, the Center on Budget and Policy Priorities published an article in 2020 stating the TANF benefits are still too low to help families, especially black families, to avoid hardship (Safawi and Floyd, 2020).This report explained that 33 states had declined federal benefits by 20 percent since 1996 and benefits continue to fall either at or below 60 percent the poverty line which impacts a household’s ability to pay for basic needs(e.g., rent). Some states have extended efforts to raise the benefits prior the pandemic. States with the lowest average grants are historically rooted in racial inequalities (Ibid). New Hampshire has modeled the economic benefit to maximizing use of TANF and funding eligible households at approximately one thousand dollars per month. This has yielded a 4.9% poverty rate in New Hampshire—the lowest record in the country—which lessens the economical burden to the state.
Education Impact on Health
While there is no official definition for “middle class,” the median income, was approximately 67 thousand dollars in 2019 (Shriner and Kollar, 2021). The difference between households of this annual median income compared to low-income households was generally the former household being more educated. During the era of slavery, education nor wages were offered to black Americans. Post slavery, black Americans were still unable to establish wealth without land, without income, and without education. Poor education and inequalities in education delivery systems directly decreases the ability to pass college admissions tests, attain employment with livable wages, increase personal income, gain economic stability and, therefore, decreases resources for healthy living. The CDC has established a correlation between low education levels with poor health outcomes. Supporting studies specifically state higher rates of biological risk levels, cardiovascular diseases, diabetes, liver disease, mental illness, comorbidities, disability or functional limitations, and premature death are associated with lower education attainment (Raghupathi and Ragupathi, 2020; Zajacova and Lawrence, 2018).
For black Americans to rise out of poverty to “middle class” earnings, acquiring a college education or working multiple jobs is most often necessary. American economist, public policy analyst, and University Professor at Columbia University, Joseph Stiglitz, explains in his book The Price of Inequality that students from abundant lifestyles could afford unpaid internships to increase resume marketability, while poor students were subjected to working to help pay for their college expenses or assist with household expenses when not afforded a scholarship (2013). To go to college in lieu of working presented a challenging dilemma for black Americans without generational wealth to help decrease the accrual of educational debt. However, those who could invest in education did so to increase access to livable wages with one job (Reich, 2013).
After the Civil War, benefits, such as the Department of Veterans Affairs education benefit (GI Bill) and expansion of colleges, made higher education more accessible and affordable to the public. However, the GI Bill did not equally extend to black soldiers. Considering the racial segregation that was instituted through Jim Crow laws and the lack of financial resources to pay for higher education, inequalities between black and white Americans persisted. Although this access has evolved since Brown v. Education, there are still significant challenges experienced in black communities that create disparities in educational outcomes from the American K-12 curriculum. In 2019, the NPR reported that in some state’s poor, primarily white school districts received 19 thousand per student while poor, nonwhite districts received only 8 thousand (Lombardo, 2019). From 2009 to 2019, the country could have seen a 2% increase in 2019 GDP of up to 705 billion dollars from increased productivity. With continued weakened education systems, the loss of growth and productivity will multiply exponentially over the next three decades. Analyses prove that investment in K-12 and postsecondary education lead to higher rates of graduation and reduced poverty in adult life (Rivera, 2021). This is corroborated through the Human Capital Theory which explains that high levels of education attainment begin a circuit of events. With increased education, wages increase, spending increases, companies can hire more, tax revenues increase, government can invest more, productivity increases, and the economy expands. The opposite occurs when education is low (Reich, 2013).
Should black students from low-income families pursue postsecondary education, the federal government provides the Pell Grant Program that funds expenses up to approximately eight thousand dollars annually. However, this still leaves a gap for cost coverage to gain quality postsecondary education that is estimated by the Department of Education at approximately 27 thousand dollars (Hanson, 2021). With this funding, black Americans gain the ability to invest more in their education increasing productivity and, most importantly, their health outcomes.
Neighborhood, Environment and Social Context Impact on Health
Through the Healthy People 2030 Campaign, the CDC recognizes that an individual’s neighborhood, environment, and social context can greatly impact their health (U.S. Department of Health and Human Services, Nd). Living in poor communities exposes Americans to safety risks to include, but are not limited to, higher rates of violence, unsafe air, unsafe water, lack of food security, limited transportation, and inadequate housing. Black Americans are most likely to live in environments that comprises of all these factors with economical challenges to elevate into safer and healthier neighborhoods.
Legislature, such as the New Deal and Federal Housing Administration’s redlining actions, revolutionized segregation—shifting black populations into urban, polluted, unsafe, and resource-restricted neighborhoods (Gross, 2017). Results of this action are still present today with these neighborhoods still under-resourced, unhealthy, and unsafe. The Environmental Protection Agency (EPA) published a report confirming black Americans being more likely of exposure to air pollution and unsafe drinking water with 75 percent overall exposure due to geographical location. This, in part, leads to higher rates of serious health problems, to include, asthma, birth defects, cancer, cardiovascular disease, infectious diseases, low birthweight, preterm delivery and premature death, in this population (Newkirk II, nd; U.S. Environmental Protection Agency. 2021).
Experiencing environmental challenges, in addition to, food insecurity, violence, limited transportation, and inadequate housing can activate a stress response in day-to-day living. With recurring and prolonged exposure to adverse or traumatic events, the stress response can become physiologically toxic causing increase heart rate, adrenaline, and stress hormones. The body regains homeostasis when the stressful event is resolved. However, constant exposure to the state of toxic stress, without a buffer, keeps the stress response activated. This constant activation manifests into social, emotional, and cognitive impairments for children ages 0-17 years and results in deterioration of the neuroendocrine, immune, metabolic, and genetic regulatory systems. These changes later develop into health risk behavior, adulthood diseases and premature death (Harvard University Center for Developing Child, nd).
Current analyses reveal a directly proportionate relationship between increased occurrences of adverse events to increased risk of heart disease, cancer, unintentional injuries, chronic respiratory disease, stroke, Alzheimer’s disease, diabetes, kidney disease, sexually transmitted diseases, and suicide attempts. These have the highest prevalence in marginalized black communities and are directly proportionate to the increased health care cost (Center for Disease Control and Prevention, nd; Maguire-Jack, Lanier, Lombardi, 2020).
Nationally, the trend for high-cost complex medical care that provides interventions for this toxic stress cascade is 20 times higher than those with low-risk medical profiles ($48,876 vs. $2,568 per year, respectively). When considering system-level government-funded programs for child abuse and neglect cases, criminal justice, special education, and low economic productivity, this expense with multiply to multi-trillions of dollars over the next 10 years (Ibid.).
Currently, some government-funded programs, such as housing assistance, SNAP, and head start provide aid with housing and food. As of 2021, 42 million Americans receive SNAP. The U.S. administration increased SNAP benefits with intent to address outdated policies, rising cost of food, and increased awareness of what constitutes a nutritious diet. Prior to this change, the U.S. Department of Agriculture (USDA) found that 90 percent of SNAP recipients struggle to eat healthier due to insufficient funding support to feed households each month. While this does not address other barriers to accessing healthy grocery shopping options (e.g., transportation, food deserts, etc), the increase is a well-directed first step towards increasing resources to healthy living. This increase has the potential to be short-lived under future congressional conventions with the influence of partisan views. This was seen in 2020 presidential campaign where the republican presidential nominee proposed to cut SNAP by 30 percent ($180 million dollars) from adults who are not working more than 20 hours each week (Rosenbaum and Neuberger, 2020).
This emphasizes the need for strengthening community resources that will help serve as a buffer in the event these programs are eliminated or decreased in the future.
healthcare on health
In 2020, before COVID-19 was fully realized in America, Brookings institute highlighted the clear, race-based inequalities in health insurance and health outcomes. Due to several states refusing to expand Medicaid benefits, people of color are far less likely to be insured. Prior to the Affordable Care Act (ACA) of 2010, nearly one in every five black Americans were uninsured compared to one in every eight white Americans. Since the provision of ACA, uninsured rates fell substantially however many states, primarily in the south and through the National Federation of Independent Business v. Sebelius ruling, elected the option to not expand Medicaid under this provision (Young, 2020; Taylor, 2019). In 2017, 58 percent of the black population lived in the south, were uninsured, and experienced the most disparate health outcomes to white Americans.
As of 2020, 11 percent of black Americans are without health insurance compared to 8.3 percent of white Americans—a 50 percent decrease (Yang, 2021). Of black Americans with health coverage, 41.2 percent participate in medicaid while 55 percent are insured through employer-sponsored or private health insurance with health care premiums being almost 20 percent the household income. These premiums are steadily increasing due to the increase cost of complex health care and exorbitant drug prices (Taylor, 2019; National Council of State Legislatures, 2018) forcing some to forfeit coverage, altogether.
Separate from affordability and access, the annual National Healthcare Quality and Disparities study compared quality of care received between black and white Americans (Fiscella and Sanders, 2016). Using the quality measures set by the Center for Medicare and Medicare Services, the following are a few examples of disproportionate outcomes for black Americans because of substandard quality care: preventative cancer screening, recommendations for cancer screening, child and adolescent vaccinations, pharmacotherapy intervention, and chronic disease control (blood pressure, heart disease, and diabetes).
Lack of Affordability and poor access to quality care leads to small numbers in preventative and comprehensive care visits in addition to the other variables that restrict access such as availability of providers, availability of services, accessibility by transportation, and accommodations for restricted time (Kullgren, McLaughlin, Mitra, and Armstrong, 2012). Access to health care was identified as a top barrier during the 2012 Institute of Medicine’s roundtable and continues to be a top barrier in 2021. The results of these barriers are most apparent in data comparing health outcomes between black and white Americans. While there are current government-funded programs, such as Medicaid, ACA, and Child Health Insurance Program, to assist low-income families, additional funding is needed to assist black families afford either public or private health insurance premiums, to include comprehensive plans, and mitigate existing barriers to help better manage their individual health.