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The Republican Party clarified its vision for post-Obamacare health coverage Monday afternoon as Speaker Paul Ryan released a draft bill. Hidden in plain sight among the details is the reality that this plan would further widen the fissures that exist not only in our health system but in our society at large.

The United States spends more money on health care than any other country in the world yet it doesn’t achieve anywhere near the best possible outcomes for its citizens. It’s true that some Americans live long healthy lives, much like those residing in the healthiest countries in the world, such as Japan and Sweden. The average lifespan of women in Fairfax, Va., right outside Washington D.C., is 85 years — three years longer than the average for women in the United States. But just 350 miles away, in McDowell County, W.Va., the average woman lives just 72 years. The gap is even wider for men.

And there are many Americans whose life expectancies are even lower than people living in developing countries such as Algeria and Bangladesh. In fact, a recent report in the Lancet showed that the overall life expectancy of Americans might soon be on par with people living in Mexico and the Czech Republic.


The reason for such large differences is that even though America appears to be one country, from an epidemiological point of view it is in fact two: the America that poor people live in is very different from the America the rich live in. Affluent Americans tend to live longer, healthier lives than poor Americans.

Take heart attacks as an example of this disparity. In research that several colleagues and I recently published, poor Americans are less likely to be prescribed lifesaving drugs such as cholesterol-lowering statins to prevent heart attacks. Such stark disparities also occur at the end of life. Despite a widespread desire to be able to take one’s last breath at home, Americans who are poor are much less likely to die at home than people who are affluent.


The American health system has not alleviated these stark differences in the health of the rich and the poor. Instead, it has exacerbated them over the past few decades. Inequities in income have such a stark effect on health in the US that they alone are the reason more than 80 percent of US counties have fallen behind in life expectancy compared to international standards.

It’s interesting to note that inequality in health is an artifact of modern medical care. Before medicine was a science, people in rich countries were as likely to live short, stunted lives as people in poor countries. The advent of medical science effectively introduced tiers of health in society, stratified by the ability to access quality care. Such disparities are vastly lessened in health systems like Canada’s, where access to care is not defined by income.

By expanding insurance coverage, particularly through expansion of Medicaid, the Affordable Care Act provided access to affordable health care for the very first time to many individuals and families who hadn’t been able to afford insurance before. The number of uninsured Americans is lower today than at any previous point in history; simultaneously, spending on health care grew at a slower rate during the Obama years than under any other recent administration.

Yet those historic achievements weren’t mentioned in any communications coming from Republican quarters. Instead, the carefully constructed narrative emerging from every crevice seeks to paint the ACA as an unmitigated disaster. The Republican draft replacement for the ACA offered a laundry list of its inadequacies.

The deliberate obfuscation of the ACA is perhaps the main reason why many who voted for Trump failed to understand that they would lose their insurance if the ACA were repealed.

Rolling back Medicaid, unlinking subsidies from income, necessitating work requirements for Medicaid eligibility — all measures championed by Seema Verma, President Trump’s nominee to head the Centers for Medicare and Medicaid — will further reduce access to health care for the poor. In essence, these changes will only increase the gap between the tiers of health and wellness experienced by different strata of American society.

The dangers of widening disparities in health between the rich and the poor threaten to have serious reverberations in a society already teeming with inequality. The irony is that many of those who will be affected by these cutbacks are people who voted Trump into power. McDowell County was the most pro-Trump county in the United States, yet it is also the county with the lowest life expectancy, driven primarily by poverty.

Income has a much stronger effect on health outcomes than even race or ethnicity, since McDowell county is 89 percent white, while Fairfax County is 53 percent white.

Physicians dedicate themselves to serving their patients and helping them achieve good and healthy lives. They do so with direct treatments that usually take the form of guidance, medications, and procedures. Yet in these times, physicians might help their patients even more by pushing their local lawmakers to recognize that there is no greater disability than poverty.

Republicans frequently use the term “able-bodied adults” to disparage poor individuals who have benefited from Medicaid expansion. That description represents a myopic view of health divorced of social context. Any physician who has treated less-fortunate patients will attest that of all the barriers to health that can be overcome in the hospital or clinic, socioeconomic constraints are the most intractable.

As lawmakers continue to explore the repeal of Obamacare and its replacement with something new (or at least borrowed), we will see if politicians take the high road and depoliticize the health of everyday Americans, or further pry open the cracks present in the fabric of our society.

Haider Javed Warraich, MD, is a fellow in cardiovascular disease at Duke University Medical Center in Durham, N.C. and the author of “Modern Death – How Medicine Changed the End of Life” (St. Martin’s Press, February 2017).