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Our guests this week are Lena Makaroun, MD, a research fellow at the VA Pudget Sound, and Sei Lee, MD, Associate Professor of Medicine at UCSF and frequent co-host on this podcast. They recently wrote a paper in JAMA Internal Medicine on wealth disparities in the US and England, and implications for mortality and disability.

Major take home points from the podcast:

  • “It’s not that great to be rich, but it really sucks to be poor.” Those in the bottom quintile of wealth had the greatest difference in disability and mortality (ie worse). Differences between those in the highest quintile of wealth and the next highest were relatively minor in comparison.
  • “Rather than saying universal healthcare doesn’t help, I would just say it’s not enough.” Worse disability and mortality with lower wealth were observed in the US and England, both before and after age 65. Does this mean National Health Service isn’t working? The authors expected to find less difference in England where universal coverage is, well universal, and not just after age 65 in the US (Medicare). The authors give thoughtful responses.

Link to the article:

-Wealth Associated Disparities in Death and Disability in the United States and England.


-By Alex Smith, @AlexSmithMD

Eric: Welcome to the GeriPal pa blah, blah, blah blah.

Alex: Wait, I have a question. Is Sei a guest or is he a cohost?

Eric: Cohost. Cohost. Are you a guest? What are you? He’s a guest.

Lena: He’s a guest.

Sei: I’m happy… I’m happy to be whatever role that you guys want me to play.

Eric: You have to introduce Sei then too.

Alex: Okay I’ll introduce Sei.

Eric: Okay

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, what are we talking about today and who do we have on?

Alex: Today we’re talking about wealth associated disparities in death and disability in the United States and England. And we have two guests today. We have Lena Makaroun who is a Health Research Fellow at the VA Puget Sound up in Seattle. Welcome to the GeriPal podcast Lena!

Eric: Welcome.

Lena: Thanks Alex and Eric, happy to be here!

Eric: And we have Sei Lee who has joined us as a cohost on previous episodes of the GeriPal podcast, but is an author on the paper that we’re going to be discussing today. Sei is associate professor of medicine here at UCSF in the division of geriatrics. Welcome back to the GeriPal podcast Sei.

Sei: Great to be here.

Eric: And Lena we ask all of our guests for a song. Do you have a song for Alex to sing?

Lena: I would love to hear Alex sing Mercedes Benz by Janis Joplin.

Eric: Very appropriate for the topic.

Alex: And Sei is gonna join.

Sei: So we’ll get started on a song of great social and political import. (Singing)

Alex: Lena, won’t you buy me a Mercedes Benz?

Lena: You know, get back to me in maybe 50 years?

Eric: So speaking of Mercedes Benzes and wealth in general …

Alex: If we only bought the people at the lowest end of the socioeconomic spectrum Mercedes Benzes!

Eric: Well maybe that’s the issue. There is Mercedes-Benzopenia …

Alex: What is the plural of Mercedes Benz?

Eric: Mercedes … Benzies?

Eric: Benzos?

Alex: I’m sorry, you were saying?

Eric: Yeah, so you just had a paper published recently in JAMA IM talking about, what was the title? Wealth-associated disparities and death and disability in the United States and England. Can you maybe take a step back and both you and Sei talk a little about why did you pick this as a topic of research.

Lena: So I did my geriatrics fellowship not too long ago over at UCSF and one of the things I kind of started to notice while I was seeing patients in the outpatient clinic was that it didn’t really seem to be the pills I was prescribing or the tests I was ordering that was having the biggest impact on their health and quality of life. In many instances, it seemed to be a lot of the social circumstances that they found themselves in. And a lot of times often their financial resources that enabled people to adapt to different changes that come with aging. So I kind of started to wonder a little bit about how wealth enabled people to age well and that kind of spurred a lot of the foundation of this retro study and I think Sei was also interested in understanding how wealth may impact peoples health and longevity. So that was kind of the birth of this project.

Alex: Is that what you’re thinking Sei?

Sei: Pretty much. I feel like this all happened with a conversation between Lena, me and a couple of other faculty members where we talked about, ‘You know it seems like sometimes the best thing we can do for older adults is provide them resources so that they can actually change their house as their abilities change.’ Or so that they can actually get more help and it very quickly went from there. Resources, how can we measure resources? What’s our other interesting perspectives on this issue that we could look into?

Alex: So there seems to be a clinical justification for this, and let’s talk more about what you did in terms of a research perspective. So what did you do?

Lena: So we used pre-existing longitudinal data sources and kind of looked at the information that was already being collected and did a secondary data analysis. So specifically we used the Health and Retirement Study, which is a longitudinal cohort study in the United States. And then the nice thing is that a lot of different countries after the United States started the Health and Retirement Study kind of modeled similar longitudinal studies in their own countries to look at a number of different health and socioeconomic variables in their own aging populations.

And so England developed the English Longitudinal Study on Aging, which we also looked at cause we wanted to kind of compare how the relationship between wealth and aging might differ in two different countries that have really different social and healthcare safety net systems. So we went ahead and looked at wealth, which was measured in those two studies by self report on a number of different variables. So for example, a lot of times when studies had been done looking at the association of socioeconomic status with different health outcomes they look at income, but we know that a lot of older adults may no longer have steady income. A lot of times they’re retired and so we were thinking income is probably not a robust enough measure of someone’s financial capacity in retirement. So what we did, we looked at a host of financial asset variables and subtracted debt and came up that was our wealth variable and we looked at how that was related to death and disability in both of those countries.

Alex: And just because I think this may come up later, what age range did you look at?

Lena: Yeah so we looked at two different age groups below and above age 65. So we looked at 54-64 year olds and then we looked at 66-76 year olds. And the reason we did that is because 65 is the age, as you know, in the United States where Medicare becomes available, but also in both countries England and the U.S., it’s around the age where the major retirement benefit becomes available. So in the US that’s social security and in England that’s something called the state pension. We made those two age categories cause we wanted to see was there a difference in the relationship before and after age 65 when you have implementation of those safety net programs?

Alex: And important also to note in England they have the National Health Service, which provides free medical care for everybody across the age spectrum, is that right?

Lena: Exactly, so from birth universal access to healthcare exactly through the NHS.

Alex: Sei any other key points about the methods? We need to leave a lot of time for the results cause there are so many interesting wrinkles to this study.

Sei: Yeah, I mean I think the thing that I would say that as most of our listeners will know this is an area looking at socioeconomic status and outcomes where there’s been a lot of studies before. But I think this study definitely does add some new things and specifically focusing on wealth I think is something that hasn’t been done very often, and also looking at disability, which older adults find as often times as important as mortality. I think those are the two main new things and that superimposed on this kind of looking at transnational comparisons made this really an interesting study to do and also kind of brought out some interesting points in the results.

Eric: Alright, so what did you find?

Lena: Well so not to get too into the weeds, but broadly what we found, is that in both the United States and in England and in both of the age categories, so both above and below age 65, low wealth was associated with increased hazard of death and disability across the wealth spectrum

Alex: So let’s unpack this a little bit cause there are a lot of different parts to this. First let’s just say, like how big are the differences in wealth in the U.S., wealth and equality. How big of a magnitude are we talking about in the difference between wealth and equality.

Lena: Right, right so what we did is we split up wealth into quintiles and so it might be easiest to talk about it that way.

Alex: Quintiles, so that’s 5 …

Lena: Exactly, so five different categories of wealth based on the proportion of people that fit into each one, so 20% of people fitting into each one. And what we found, so for example, for the lowest age group in the United States, the poorest group had an average wealth of about $6500. And when you compare that two the richest group, the richest group had an average wealth of about $1.5 million so really a huge range there. And we saw similar ranges when we looked at the older age group in the U.S. it was about $8000 for the poorest. So you do see as you get older, you are able to accumulate a bit more wealth, but again compared to the richest who had about 1.4 million really, really big difference. And we saw similar differences in England. I’ll just give one example, and these are in pounds, which is the English currency. So the older age group in England, the poorest had about 5000 pounds of wealth and the richest had about close to 600,000 pounds of wealth.

Eric: And remind me again, wealth is defined as all of your … home minus debt?

Lena: Right, so it’s cumulative assets minus debt. So just to give you an example, assets included things like the value of property, vehicles, savings accounts, stocks, bonds, retirement accounts, things like that.

Eric: And how good are people at accurately defining their wealth?

Lena: That’s a good question, I actually don’t know the answer, I have to presume there probably is some measurement error there because it is a self-reported thing. However, I would assume that whatever error is going in would be similar in both groups. But ya I don’t actually know.

Sei: I think the one thing that I would say is this is actually a critical component of both the Health and Retirement Study and the English Longitudinal Study on Aging. So they ask a lot of questions about this and try to drill down to the level of, if people are uncomfortable, for example, giving a specific number for one of these values, they ask bracketing questions of, “Oh is your health worth more than this amount?”, “Is it worth less than this amount?” So that we try to get as much information as possible. But as you can imagine this is a sensitive question, and so there may be inaccuracies introduced by reporting. I think what Lena was talking about was that it’s unlikely that the inaccuracies are systematic and all in one direction so that we’ll get grossly biased results.

Eric: Alright, so wealthy people live longer?

Lena: Yes.

Eric: What do I do with … That seems like it has good face validity, but I’m not 100% sure like what we should do with that.

Lena: So you know, I don’t know that there’s something that doctors on an individual basis are going to do with that information. To me, the biggest implications of these types of findings are for policy makers and people kind of at health system or leadership positions that are thinking about, for this population of people, how do I reduce disparities in longevity and disability? And in thinking about that, I think what this paper really showed is that you can’t just think about access to healthcare. So for example, we didn’t really see a major attenuation in this relationship in England where they have universal healthcare from birth, or in the U.S. after age 65 once Medicare comes into effect, we really didn’t see a major attenuation of this effect.

So thinking about, how do we then narrow this gap, I think we have to think outside of healthcare to fiscal and social policies and probably target those interventions much earlier in the lifespan. So probably by the time you’re in your 50’s and 60’s, you’ve already experienced the cumulative stressors over your life that result from low wealth and it may be that the impacts that those have on your health and your function, it’s too late to kind of change those later in your life.

So to me those are two of the big takeaways, and really I think those are for people in positions of leadership, but also for us individually to advocate for those types of things. I think as healthcare providers and physicians in particular, we are trained in the biomedical model of how to intervene and improve health, but health we know is the result of so many more things than just therapeutics. So I think advocating for policies that address some of these wealth-related disparities is something that we can all do.

Alex: I have to say I was somewhat disappointed to read that at age 65, in the U.S. there was no change and that the same disparities in disability and mortality by wealth were present in the UK where they have a National Health Service as they were the U.S. I was hoping that this would be an argument for universal healthcare coverage.

Lena: I know.

Alex: Across the age spectrum, but unfortunately this is not that article. Sei, you look like you were gonna say something?

Sei: So I mean I think that was certainly one of our hypotheses going in, and I think what the lesson that I take away from this, as a doctor, I think too highly of what doctors do. We think that hospitals and being able to see doctors are going to be so important and I think on an individual case by case situation that may absolutely be true here and there, but on a population level, exactly as Lena said, what we see is that the differences that we see across wealth, doesn’t really change very much just because somebody gets to the age of 65 and now they have Medicare in the United States and are able to see the doctors. The transition, the relationships between wealth and disability and death in the UK where they have insurance at the National Health service, throughout the age spectrum is identical to the US where some folks don’t have health insurance until age 65 and then they get it.

Lena: Yeah and Alex, I shared your kind of head in hands moment when we saw these results and I kind of crossed my fingers and thought oh God that this is not interpreted as an argument against universal healthcare, which I’m a huge proponent of. I think what I would say, is that number 1 we didn’t look at, there’s a number of other benefits that have been shown resulting from universal healthcare – reduced medical debt, improvement in having usual source of care, improvement in access to care … there’s a number of benefits that we didn’t look at. We were looking at two very specific outcomes. The other thing is, rather than saying universal healthcare doesn’t help, I would just say it’s not enough. It’s important, and for a lot of other outcomes, its very, very important, but probably when we’re looking to move the needle on really big outcomes like mortality and disability especially in older age categories, we need more. The other thing I just wanna highlight is that we didn’t actually do statistical comparisons looking at comparing the US and England, or comparing above and below age 65, it was more of a qualitative comparison looking at the graphs of the trends.

Sei: So I wanted to kind of put a couple of things that I think are takeaways that I’m taking away from this article. Number 1 it’s not that great to be rich, but it really sucks to be poor. So if you look at the people at the top quintile do versus the people at to second top quintile do in terms of both death, mortality and disability, there’s really not that much difference whether you’re in the top quintile or second to top quintile. However, on the other side of the spectrum, it really sucks to be at the bottom rung in terms of the wealth spectrum in both Health and Retirement Study and in the U.S. and in England, being at the bottom quintile really puts you at much higher risk of death and much higher risk for disability. So it really sucks to be at the bottom of the socioeconomic scale in both countries.

Alex: Right, and we have going through both Congress and Committee right now, a tax bill that largely favors the wealthly. And favors the poorest group the least. So this has important implications for public policy beyond health policy and implications of things like taxation and income inequality.

Sei: Yeah, I think other studies have previously shown this as well, but we did quantify kind of the level of income disparity in the US versus the UK, and we did find that there was more income inequality in the US.

Lena: And wealth, so wealth and income inequality were both greater in the U.S. than in England and also what was interesting was to see that there is actually greater wealth disparity compared to income in both countries. So I think of wealth as kind of a marker of your lifelong kind of what you’ve been able to accumulate. When you look at that it kind of takes into account someone’s circumstances throughout their life and it turns out that there’s more disparity in wealth later in life, than there is in income even.

And regarding the tax bill I would say I think it’s very concerning. I think one of the things that’s heartening about what our paper showed was that, as Sei mentioned, it’s really bad to be the poorest. When we look at the lowest wealth quintile, they’re really not doing so well, but the biggest improvement in health outcomes that we saw, were going from the lowest wealth quintile to the second lowest wealth quintile. So relatively small gains in wealth at that low end of the spectrum actually resulted in the biggest improvements and outcomes.

Alex: So you don’t need to buy ’em a Mercedes Benz.

Lena: Exactly.

Alex: You could buy him a Honda. A used Honda!

Lena: Just trade in their bus pass for a used Honda, but you know I think that’s heartening, and I think that has a lot of relevant policy translation in that it doesn’t have to be that much. And there’s really some interesting stuff going on … there’s a mayor where they’re piloting universal income for the entire city, but you know thinking about novel things outside the box like that and understanding that at kind of at a basic level people need a certain amount to avoid kind of chronic housing instability, chronic stress, susceptibility to drug and alcohol abuse, all these things that down the line are really going to impact health.

Alex: Yeah it’s fascinating and think about all these countries or places where they have programs that boost everyone, but just by the numbers it boosts the lowest the most. So $25 is not that much to somebody who has a wealth of 1.5 million, but to someone who has a wealth of 8000 it probably means something.

Sei: A lot.

Lena: Right

Sei: I think the other point, the other kind of finding that I want to make sure doesn’t get lost, is how common disability was in both even the younger groups in the US and England, we found 40-50% of those in the lowest wealth quintile in the 54-64 age group, 40-50% had difficulty with ADLs. Usually we think about activities of daily living difficulties is something that happens to people in their 70s, something that happens to people in their 80s and so this is definitely earlier than we would expect and it shows how the stress of having low wealth, low socioeconomic status is making some of these really middle-aged adults look a lot more like older adults.

Alex: Interesting, so any idea how this played across the pond in England, what was the reaction to this article?

Lena: Well I haven’t been on my social media British connections, but there was an editorial that was written about the article by a British author and they seemed to … I mean I think there’s some surprise, but also recognition at the same time that this is still a problem in England and I think that on the ground there they recognize that, but I don’t know Sei have you had any other feedback from English colleagues or friends?

Sei: I have not, and I think that is on a … I was struck by the editorial talking about how one of the political problems of focusing on the lowest wealth groups is that it’s very politically easy for that to get demonized as kind of class warfare, we’re helping the other. Whereas successful programs actually are much more universal in their nature, as Alex mentioned previously, if we give $25 to everybody, if we give a certain amount to everybody, it will have the natural effect of having the greatest impact for those at the bottom of the socioeconomic ladder because relatively it will mean so much more to them. And politically it is much more stable and often times durable solution. So this finding is certainly not the first time that this finding has come about and so there is definitely a segment of the readership that has already been thinking about how to implement this and as you alluded to before this is not necessarily at about what can an individual doctor do, but how can we take a second look at the systems we have in place to try to avoid some of these systemic inequalities.

Lena: And even though this is difficult time I think in many ways for health policy in the United States, it’s also a really ripe time for doctors and other healthcare professionals and public health professionals who care about these issues to have their voices heard and kind of speak up about evidence based policies that might help reduce some of these disparities.

Eric: So is there a next step for both of you as far as this research line of thought?

Lena: So one thing that is, like I mentioned earlier in the podcast, there’s a number of different countries that have similar kind of sister data sets, so it might be interesting to see are these findings replicated in other countries that even have different types of systems? So that’s one potential next step in terms of seeing where this type of relationship does and doesn’t exist. I guess the really interesting next step would be testing potential interventions, so in some of these smaller local places where they’re trying different types of income-based or financial policy based interventions to help people, the problem is always the outcomes that you’re gonna see are really far down the line and it’s delaying gratification like that is always really hard especially in scientific fields where we wanna see the impact of our interventions.

Eric: Maybe to sum up, like what do we actually do with this information? So we have further evidence to support that …

Lena: Call your senators … sorry go ahead.

Eric: So we have more evidence to suggest that wealth and income impact healthcare and more evidence to suggest that as clinicians as healthcare providers we may not have as much impact as we think we do and that other determinants of health, like income and wealth play a big role in how people do later on, on morbidity and mortality. Does that sound like a reasonable summation of this article?

Lena: Yeah I think so. We certainly want doctors to keep being good doctors and keep delivering good medical care. I would say perhaps an implication on a day to day practice basis, is that what that means is probably thinking outside of the pills and the tests, and thinking what are the social circumstances that my patient is in and how should I be taking that into account? But also I think it is stepping outside of the clinic, outside of the hospital and entering the realm of policy and how do we as a society advance public health and health for the whole population? There’s a really interesting and I found really inspirational, Piece of My Mind by Don Berwick last week, where he’s essentially making the argument that we as doctors and healthcare providers and health systems don’t have the choice to be silent anymore because the preponderance of evidence is too strong now that if we actually care about health of our patients we can’t just focus on medical care and we really have to care about the other things. And so having an active voice in that is really important.

Eric: Wonderful. How about we’ll end with a little bit more of a song. Thanks for both of you for joining us today at this GeriPal podcast.

Alex: Thank you!

Lena: Thank you guys!

Sei: Yeah (Song).

by: Annette Rodriguez

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