Raising Income to Protect Health

The American Public Health Association,

Recognizing that APHA supports the right of all persons to a freely chosen job paying wages sufficient to support a dignified existence. [APHA Policy Statement 9508]; and

Finding that US has the second highest prevalence of child income poverty (22%) among wealthy countries, and most poor children live in families with at least one working parent;¹ and

Understanding that Healthy People 2010 goals specifically recognize income and educational attainent as determinants of health status; however, the goals do not identify narrowing disparities in these economic and educational determinants;² and

Realizing that it is unlikely that increasing access to health care services or targeting public health messages to communities in poverty alone will eliminate health disparities;^3-5 and 

Recognizing that data from longitudinal studies in the United States consistently demonstrate that low income predicts premature mortality for all causes across the distribution of income and independent of other socioeconomic correlates of income;^6-11 and

Acknowledging that low income is inversely associated with poor subjective health status and functional limitations;^12-15 and

Recognizing that socioeconomic factors in childhood have been shown to predict health status in adult life, indicating that socioeconomic influences may be cumulative, have latent effects, or set an individual on a particular health trajectory;^16,17 and

Finding that educational attainment is raised and risk of single parenthood lowered due to increased family income;¹⁸ and

Understanding that increased family income may support better utilization of primary care, likely forestalling ambulatory care sensitive hospitalizations.^19-21

Recognizing existing labor and tax policy tools including the minimum wage and the “Earned Income Tax Credit” could be used to raise income for the working poor; and

Recognizing that the explicit health costs of poverty are not included in the calculus or public discourse regarding minimum wage and tax policy; and

Recognizing that local “living wage” ordinances have passed in more than 30 municipalities that increase wages to a level providing for the minimum average family’s needs for housing and utilities, food, transportation, childcare, health care, and taxes; therefore recommends that

1. The prevalence of low income be an explicit health status indicator and reducing the prevalence of low income become a national public health objective;
2. Federal, state, and local governments should consider and evaluate labor and tax policies to increase income to minimum sustenance levels for the working poor as an explicit public health intervention; conversely, costs and benefits to health should be explicitly considered in policy debates regarding the minimum wage and eligibility thresholds for the Earned Income Tax Credit;
3. Epidemiologic studies should be done specifically to evaluate the effectiveness of income-supporting policies on public health; these may include studies that look at the effect of income dynamics on health outcomes7,18 or studies of “natural experiments” of public policy such as local living wage ordinances or changes in tax or entitlement laws; and
4. APHA members should initiate and inform a public dialogue regarding the effect of income on health; an informed public is particularly important in light of the primary emphasis of media and advertising messages on individual behavior changes, pharmaceutical interventions, and the importance of health care services and institutions.

References

1. UNICEF-Innocenti Research Center. Innocenti Report Card 1: A league table of child poverty in rich nations. 2000.
2. Healthy People 2010, http://web.health. gov/healthypeople/document/tableofcontents.htm 
3. Adler N, Boyce W, Chesney M, Folkman S, Syme S. Socioeconomic inequalities in health. No easy solution. Jama. 1993; 269(24):3140-3145.
4. Anderson GF, Poullier JP. Health spending, access, and outcomes: Trends in industrialized countries. Health Affairs. 1999.
5. Geronimus AT. To mitigate, resist, or undo: Addressing structural influences on the health of urban populations. Am J Public Health. 2000; 90(6):867-872.
6. Backlund E, Sorlie PD, Johnson NJ. The shape of the relationship between income and mortality in the United States. Evidence from the national longitudinal mortality study. Annals of Epidemiology 1996; 6(1):12-20; discussion 21-2.
7. Mcdonough P, Duncan GJ, Williams D, House J. Income dynamics and adult mortality in the United States, 1972 through 1989 [see comments]. Am J Public Health. 1997; 87(9):1476-1483.
8. Fiscella K, Franks P. Poverty or income inequality as predictor of mortality: longitudinal cohort study [see comments]. BMJ. 1997; 314(7096):1724-1727.
9. Sorlie PD, Backlund E, Keller JB. US mortality by economic, demographic, and social characteristics: The national longitudinal mortality study [see comments]. Am J Public Health. 1995; 85(7):949-56.
10. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: Results from a nationally representative prospective study of us adults [see comments]. Jama. 1998, 279(21):1703-1708.
11. Leclere FB, Rogers RG, Peters K. Neighborhood social context and racial differences in women’s heart disease mortality. Journal of Health and Social Behavior. 1998; 39(2):91-107.
12. Marmot MG, Fuhrer R, Ettner SL, Marks NF, Bumpass L, Ryff CD. Contribution of psychosocial factors to socioeconomic differences in health. Milbank Quarterly. 1998; 76(3):403-448, 305.
13. Kennedy BP, Kawachi I, Glass R, Prothrow-Stith D. Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis. BMJ. 1998; 317(7163):917-921.
14. Ettner SL. New evidence on the relationship between income and health. J Health Economics 1996; 15(1):67-85.
15. Geronimus AT, Bound J. Use of census-based aggregate variables to proxy for socioeconomic group: Evidence from national samples. Am J Epidemiology. 1998; 148(5):475-486.
16. Kuh DJ, Wadsworth ME. Physical health status at 36 years in a British national birth cohort. Social Science and Medicine. 1993; 37(7):905-916.
17. Keating DP, Hertzman C. Developmental Health and the Wealth of Nations. New York, NY. Guillford Press, 1999.
18. Duncan GJ, Yeung W, Brooks-Gunn J, Smith JR. How much does childhood poverty affect the life chances of children? American Sociological Review. 1998; 63(3):406-424.
19. Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: Inequalities in rates between us socioeconomic groups. Am J Public Health. 1997; 87(5):811-816.
20. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: Risk factors, reasons, and consequences. Annals of Internal Medicine. 1991; 114(4):325-331.
21. Himmelstein DU, Woolhandler S. Care denied: US residents who are unable to obtain needed medical services. Am J Public Health. 1995; 85(3):341-344.

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