By Kyle K. Moore
Stark racial divisions along economic and social lines have long been and continue to bedefining features of American life. Health disparities across racial groups are considered downstream consequences of these economic and social divisions. Neoclassical economics, political economy, andstratification economics provide potential explanations for health disparities. Preliminary support forthe stratification approach is provided in the research. Understanding the causes of racial healthdisparities is crucial in developing better policy solutions to those disparities.
Stark racial divisions along economic and social lines have long been and continue to be defining features of American life. Health disparities across racial groups are considered downstream consequences of these economic and social divisions (Gehlert et al., 2008). Mortality differences between blacks and whites can largely be attributed to racial differences in socioeconomic status (Bosworth, 2018). As for morbidity (the incidence of disease and disability), the relationship is a two-way street: lower socioeconomic status leads to worse health, and worse health affects a person’s capacity to earn income and build wealth (Smith and Kington, 1997).
There are clear racial differences in the incidence of chronic diseases most associated with lower income, lower wealth, and higher mortality. Blacks are more likely to experience hypertension, stroke, heart disease, obesity, and diabetes than are their white counterparts (Cunningham et al., 2017). However, even when taking differences in socioeconomic status into account, racial differences remain (Thorpe et al., 2011). How to explain the remaining differences in health between blacks and whites in the United States? Three possible approaches are those given by neoclassical economics, political economy, and stratification economics.
The neoclassical economics approach to health emphasizes the roles of individual behavior, preference, and inborn characteristics, such as genetics (Becker, 2007). Neoclassical health economists use a “health production function” to model the way individuals invest in their own health. In this model, individuals decide whether or not to invest in their health by balancing the costs of healthcare and healthful goods against other personal wants and needs.
The tools available to neoclassical economists lead them to explain disparities in health as the result of either poor health behaviors or inborn biological predispositions toward poor health. While behavior and genetics play important roles in determining health differences at the individual level, because race is a social category that determines neither individual behavior nor genetic makeup, they are of limited use in explaining racial health disparities (Silverstein, 2015).
Political economy provides one alternative to the neoclassical approach by instead focusing on the effects of the political and economic environments on population-level health trends.
Historically, the most significant reductions in mortality and morbidity in the United States have happened as a result of politically determined, hard-won improvements in economic and living conditions for masses of people—from public sanitation, to labor laws, to environmental regulation (Chernomas and Hudson, 2013). Today, gains in life expectancy disproportionately go to those at the higher ends of the wealth, income, and educational distributions, and those at the bottom disproportionately face disease burden (Sanzenbacher et al., 2017).
The political economy approach grapples with the ways capitalism shapes people’s life chances differently based upon how they earn their living, and with the ways large groups of people—not just individuals—are barred from reaching their health potential through a lack of economic resources. As a framework for explaining racial disparities in health, political economy is an improvement over neoclassical economics, as it says that the stark economic disparities between blacks and whites in the United States account for a significant portion of health disparities between those two groups. However, because racial disparities in health remain, even after accounting for differences in wealth and income, further investigation is required to reach an adequate explanation of racial gaps in health.
Stratification economics provides another alternative approach to explaining racial health disparities. Stratification is the process by which dominant groups in society create laws, shape institutions, and enforce policies and norms such that those groups maintain and improve their position relative to the disadvantaged. The United States is marked by a history of racial stratification, in which non-white racial groups have been consistently disadvantaged relative to their white counterparts. Stratification economics combines economic tools with those of sociology and social psychology to understand the causes and consequences of group-based stratification (Darity et al., 2017). A stratification approach to health disparities focuses on the historic social and political circumstances that have led to disparity—the institutions, laws, and norms that stratify society and allow disparities to perpetuate, and-or the material conditions that are the basis for disparity (not unlike the political economy approach).
Scholars in social psychology, epidemiology, and sociology investigate the role that stress, induced by exposure to racial oppression, stigma, and discrimination, plays in shaping health disparities (Williams and Mohammed, 2009). Constant activation of the systems that the human body uses to mitigate stressful situations causes several morbidities (collectively referred to as “allostatic load”), including hypertension and inflammation (Howard and Sparks, 2016).
Colen and colleague’s (2018) research investigates the role exposure to “everyday discrimination” plays in worsening physical and mental health among black Americans; alongside this, similar research by Sturgeon et al. (2016) investigates the same health consequences for exposure to financial strain. Stress can be defined as the circumstance wherein an individual appraises their available resources as inadequate for meeting a situation’s demands (Brondolo et al., 2017).
Recent Stratification Economics Study on Health Disparities
An investigation of racial health disparities from the stratification economics perspective, using a sample of working, non-Hispanic black and white respondents ages 50 to 64 from the Health and Retirement Study (between 2006 and 2010), showed the following:
√ Blacks are more likely to experience both high exposure to potential stressors (everyday discrimination and financial strain) and low economic resources (wealth and income); and
√ This combination (i.e., “stress”) is associated with higher rates of hypertension or inflammation.
Blacks are more likely to be in the bottom quintile of wealth or income than are whites (48 percent versus 21 percent), more likely to face above-median expo- sure to financial strain or everyday discrimination (72 percent versus 55 percent), and are more likely to face the combination of low resources and high exposure—“stress” (37 percent versus 16 percent). Experiencing this “stress” in 2006 or 2008 is associated with higher rates of hypertension, inflammation, and self-reported fair or poor health for both blacks and whites in 2010 and 2012.
While further research is required to establish causal relationships, the work thus far points to the importance of considering both economic resources and exposure to potential stressors in explaining racial health disparities. The stratification economics approach can guide us toward better theories for explaining the stark group-based economic and social disparities that characterize the United States.
It also should guide us toward policies that target the laws, institutions, and norms that maintain disparity, rather than the individuals most disadvantaged by stratification. One example of such a policy could be a federal jobs guarantee, which could help to circumvent racial discrimination in the labor market (Paul, 2018). The current understanding of the causes of racial health disparities must be reoriented in order to move forward on developing better solutions to address these disparities.
Kyle K. Moore, a senior policy analyst with the United States Joint Economic Committee (Democrats) in Washington, D.C., is pursuing a doctorate in Economics at The New School for Social Research, in New York City.
Becker, G. S. 2007. “Health as Human Capital: Synthesis and Extensions.” Oxford Economic Papers 59(3): 379–410.
Bosworth, B. 2018. “Increasing Disparities in Mortality by Socioeconomic Status.” Annual Review of Public Health 39: 237–51.
Brondolo, E., et al. 2017. “Stress and Health Disparities: Contexts, Mechanisms, and Interventions Among Racial/Ethnic Minority and Low-socioeconomic Status Populations.” American Psychological Association (APA) Working Group Report. Washington, DC: APA.
Chernomas, R., and Hudson, I. 2013. To Live and Die in America: Class, Power, Health, and Healthcare. London, UK: Pluto Press.
Colen, C. G., et al. 2018. “Racial Disparities in Health Among Non-poor African Americans and Hispanics: The Role of Acute and Chronic Discrimination.” Social Science & Medicine 199: 167–80.
Cunningham, T. J., et al. 2017. “Vital Signs: Racial Disparities in Age-specific Mortality Among Blacks or African Americans— United States, 1999–2015.” Morbidity and Mortality Weekly 66(17): 444–56. tinyurl.com/y2wlhhdj. Retrieved August 20, 2019.
Darity, W. A., Jr., et al. 2017. “Stratification Economics: A General Theory of Intergroup Inequality.” In A. Flynn et al., eds., The Hidden Rules of Race: Barriers to an Inclusive Economy. Cambridge, UK: Cambridge University Press.
Gehlert, S., et al. 2008. “Targeting Health Disparities: A Model Linking Upstream Determinants to Downstream Interventions.” Health Affairs 27(2): 339–49.
Howard, J. T., and Sparks, P. J. 2016. “The Effects of Allostatic Load on Racial/Ethnic Mortality Differences in the United States.” Population Research and Policy Review 35(4): 421–43.
Paul, M. 2018. “A Path to Ending Poverty by Way of Ending Unemployment: A Federal Job Guarantee.” Journal of the Social Sciences 4(3): 44–63.
Sanzenbacher, G., et al. 2017. “Rising Inequality in Life Expectancy by Socioeconomic Status.” Chestnut Hill, MA: Center for Retirement Research at Boston College.
Silverstein, J. 2015. “Genes Don’t Cause Racial-Health Disparities, Society Does.” The Atlantic, April 13. tinyurl.com/yyfbpdrt. Retrieved August 12, 2019.
Smith, J. P., and Kington, R. 1997. “Race, Socioeconomic Status, and Health in Late Life.” Washington, DC: The National Academies Press.
Sturgeon, J. A., et al. 2016. “The Psychosocial Context of Financial Stress: Implications for Inflammation and Psychological Health.” Psychosomatic Medicine 78(2): 134.
Thorpe, R. J., Jr., et al. 2011. “Racial Differences in Mortality in Older Adults: Factors Beyond Socioeconomic Status.” Annals of Behavioral Medicine 43(1): 29–38.
Williams, D. R., and Mohammed, S. A. 2009. “Discrimination and Racial Disparities in Health: Evidence and Needed Research.” Journal of Behavioral Medicine 32(1): 20–47.