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June 2022 (Volume 100)
Quarterly Article
Seth A. Berkowitz
December 2024
Back to The Milbank Quarterly
Policy Points:
Three key “branch points” for designing policy approaches to address income-related health inequity are (1) should the needed good or service be obtained on the market? (2) do policy beneficiaries currently earn income? and (3) have policy beneficiaries earned income previously? The responses to these questions suggest one of four policy approaches: social services, social enfranchisement, social insurance, or social assistance.
Social conditions give rise to material realities. The social conditions structuring access to those resources “necessary to lower the risk of developing a disease, or minimize the consequences of a disease once it occurs” can be thought of as the fundamental causes of health. In this characterization, income is an archetypical example of a fundamental cause.
Though it is by no means the only factor, achieving and maintain- ing health requires sufficient consumption of particular goods and services across the life course. These goods and services include nutritious food, safe housing, education, and health care. In the United States’ political economy, these goods and services are typically obtained on the market, which has made income a principal driver of health as well as a fundamental cause of many diseases through many mechanisms. Furthermore, racism is a fundamental cause of disease in its own right. A common manifestation of structural racism in the United States is lower income among those persons identifying as Black, Hispanic, or Indigenous. This makes income one, though certainly not the only, explanation for the unjust health outcomes often experienced by individuals from minoritized racial and ethnic groups.
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