When Pamela D., 70, was diagnosed with chronic lymphocytic leukemia (CLL) in January 2022, she was in shock. Her first worry was, "Where do I go from here?" Her second was, "How will we afford it?"
The annual cost to treat CLL is about $106,000. Retired and living on a fixed income from Social Security checks and a teaching pension, she and her husband were unsure if they would be able to make ends meet. Even with Medicare coverage and a supplement, the pair found themselves with $5,000 in medical expenses that they could not afford.
"We decided that we would do whatever was necessary, but it's so frightening," Pamela says. A generous grant from the HealthWell Foundation, a nonprofit organization that helps with out-of-pocket expenses, helped. So did some pharmacy assistance from The Center for Cancer and Blood Disorders in Fort Worth, TX.
The financial burden is even greater for people who lack supplemental insurance. Almost 10% of older adults with Medicare spend more than 60% of their annual household income on out-of-pocket costs after being diagnosed with cancer.
And for people who don’t yet qualify for Medicare, the burden can be even higher. For those without sufficient insurance or income, regular health care can be financially difficult – but for those who get seriously ill, it can become financially impossible.
The Affordable Care Act can help provide insurance, but only if you can afford to pay for it.
The Income-Health Gap
America is a leader in medical innovation. We spend much more on health care than other developed nations.
And yet huge disparities in health outcomes remain. Low-income Americans are more likely to be in poor health than higher-income Americans. They have higher rates of obesity and smoking, which are linked to negative health outcomes. And they're less likely to have health insurance or access to preventive care.
About 10% to 20% of health outcomes are associated with health care. The rest have to do with social and economic factors, including income, says Steven Woolf, MD, of the Center on Society and Health at Virginia Commonwealth University.
In 2009, he led a study in Virginia that found that people with higher incomes had better health outcomes. Some quarter-million deaths between 1990 and 2006 were linked to lower household incomes.
But they also found that it’s not always easy to separate income itself from other social and economic factors like age, gender, education, race, and ethnicity. Education was particularly powerful. Woolf’s study found that a lack of education beyond high school could account for 75% of these avoidable deaths.
Income interacts with these factors in complex ways that can take a toll on your health. For example:
Health insurance: Fewer than one-third of low-income workers have health insurance, compared to nearly 60% of higher-income workers. When you don't have insurance, you might delay or skip doctor visits, tests, and treatments because you can't afford these services. If you miss preventive visits for a chronic condition like heart disease or diabetes, the disease could get worse. Even for people who have health insurance, high copays and deductibles can make health care expensive, sometimes too expensive to afford. Prescription drugs and screening tests may be out of reach for people who live below the poverty line.
Transportation and access: It's harder to get to doctor appointments or to the drugstore to refill a prescription when you don't have a car, time off from work, or child care. And if you live in a low-income or rural area, doctor shortages might mean there's no one to see you if you get sick.
Diet and exercise: People who eat a well-balanced diet, who exercise, and don't smoke live longer than those who don't follow these healthy habits. Yet these practices can be hard to maintain for people who live paycheck to paycheck.
Low-income neighborhoods have fewer supermarkets and more fast-food restaurants than wealthier ones. They also lack sidewalks, parks, and green spaces. Exercising indoors can be a problem in these areas, too.
"Amenities like going to the gym that help us with physical activity are difficult, not only because it costs money to have fancy athletic equipment, but because people who have to work multiple jobs don't have the kind of time to be exercising," Woolf says.
Stress: When we're under constant stress, our bodies produce hormones that increase our risk for chronic diseases like diabetes, cancer, heart disease, and depression. The unhealthy tools some people lean on in times of stress – alcohol, cigarettes, or drugs – only add to their health risks.
Living in a low-income neighborhood where you're surrounded by crime and violence without social supports can be extremely stressful. Stress might even reshape your genes by shortening part of your chromosomes called telomeres. Shortened telomeres have been linked to heart disease and other serious health conditions.
The erosion of economic prosperity contributes to stress, too. There was a time when a job at the local factory offered a lifetime of financial security and benefits. "The rug's been pulled out from all of that," Woolf says.
"There's a sense of hopelessness that's affected many Americans. That's not something that you can measure in dollars and cents, but it's a palpable factor that's affecting health."
Pollution: The poor carry the burden of pollution in the United States. Many low-income communities are close to highways, manufacturing plants, or airports. More than 9,000 low-income apartments sit within a mile of hazardous waste sites. Studies show that people who are regularly exposed to pollution have higher rates of asthma and other lung diseases.
The air inside these homes may not be much cleaner. Low-income housing developments are plagued with problems like lead paint, dust mites, and mold.
Weather: Less affluent neighborhoods are also more vulnerable to severe weather. Affordable housing is more likely to be in flood zones. In New York City, nearly 5,000 of these housing units are at risk of flooding every year. The number of low-income housing units in flood zones is expected to triple over the next 3 decades due to climate change.
Low-income communities are also more likely to be in urban heat islands – parts of cities where the temperature is higher than the surrounding areas. And they may not have access to air conditioning. "During summer, those neighborhoods have been shown in studies to have much higher rates of [hospital] admissions for heat-related illnesses," Woolf says.
Race, Income, and Health
When you add race to the equation, the burden on health increases even more. Black people are nearly twice as likely to live below the poverty level than white people. They also have higher death rates from all causes.
Wealth seems to divide along racial lines, and it’s hard to ignore the long history of racism in America as a root cause of this disparity. "The effects of segregation on a community affect health," Woolf says. "They are more likely to end up with the consequences of social and economic resources being cut off from their neighborhoods."
Even the feeling of prejudice from others can take its toll. One study linked higher race-based stress to high blood pressure among Black Americans.
People of color often fare worse when it comes to chronic conditions like rheumatoid arthritis, but it’s not clear whether this is solely due to race, or to other things like social and economic class. Some experts say it is hard to separate race from socioeconomic, demographic, cultural, and behavioral factors because there has historically been so much bias and prejudice in the medical system, and in society overall.
How to Narrow the Gap
One way to narrow the health divide is with government policy, says Paula Braveman, MD, director of the Center for Health Equity at the University of California, San Francisco.
She points to the Earned Income Tax Credit (EITC) and the more recent Child Tax Credit as examples of programs that are helping people rise out of poverty. These programs give tax breaks and refunds to people of low and moderate income.
Putting money toward our children's future is important, too. Government investments in education would give children a chance to succeed by allowing them to go to college, Braveman says.
In the meantime, programs are available to help Americans who are struggling to pay for health care, including EITC. Area Agencies on Aging and the Health Resources & Services Administration (HRSA) help seniors find affordable services. And organizations like the HealthWell Foundation, the Pan Foundation, and the National Association of Free & Charitable Clinics reduce financial barriers to health care.
The financial support Pamela has received from the HealthWell Foundation has been critical to her getting the treatment she needs.
“We’re grateful,” she says. “I’m healthier than I’ve been in a long while. We’re living life every day. We’re enjoying our friends and our family.”