61 pages • 2 hours read
David A. AnsellThe Death Gap: How Inequality Kills
Nonfiction | Book | Adult | Published in 2017A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Part 3, Chapters 9-10Chapter Summaries & Analyses
Part 3: “Health Care Inequality”
Part 3, Chapter 9 Summary: “The US Health Care System: Separate and Unequal”
Ansell identifies three primary reasons for the inequalities in the US healthcare system: Healthcare being treated as a commodity rather than a right; implicit racial bias; and the resource constraints faced by healthcare institutions serving disadvantaged communities. These factors collectively lead to poorer health outcomes for minorities and the poor.
One example of healthcare disparity is the higher breast cancer mortality rate among Black women compared to white women. Despite similar incidence rates, Black women are 40% more likely to die from breast cancer, primarily because they tend to be diagnosed at more advanced stages. As Ansell explains, the discrepancy is not biological but is caused by structural violence. The quality of breast cancer screening and treatment is often lower in predominantly Black neighborhoods due to under-resourced facilities and less-specialized care, leading to missed diagnoses and delayed treatments.
Ansell recounts the story of a middle-aged African American woman whose obvious breast cancer was missed in a mammogram read by a non-specialist radiologist. This incident underscores how lack of access to quality care contributes to higher mortality rates. While the task force’s efforts, including the employment of health navigators to guide patients to high-quality care, have led to some improvement, many challenges remain. Such challenges include the continued existence of lower-quality facilities in poor neighborhoods like in Washington Park, with a mammography room filled with sewer fumes.
Ansell notes that implicit bias among healthcare providers is another significant factor contributing to the death gap. Studies have shown that physicians, often unconsciously, provide different levels of care based on patients’ race and insurance status. This bias can lead to less thorough diagnostic evaluations and treatments for Black patients, contributing to health disparities.
Additionally, the lack of health insurance aggravates the situation. Uninsured adults are more likely to forgo necessary medical care due to cost, leading to worse health outcomes. Before the Affordable Care Act was introduced in 2010, an estimated 45,000 Americans died each year due to lack of insurance, highlighting the critical need for universal healthcare coverage.
Hospitals that serve predominantly minority populations often have higher mortality rates across various conditions, including trauma and cardiac surgery. These institutions are typically under-resourced, with fewer financial and capital investments compared to hospitals in wealthier, predominantly white neighborhoods. For example, during Ansell’s tenure at Mount Sinai Hospital, a safety-net hospital in a low-income neighborhood, the hospital faced significant financial constraints and struggled to provide high-quality care.
Ansell concludes by discussing the American Hospital Association’s Equity of Care Campaign, which aims to address healthcare disparities by encouraging hospitals to measure and improve their quality of care. However, he emphasizes that real change requires more than just pledges: It necessitates structural reforms, including national health insurance reform, to ensure that health care is treated as a fundamental human right.
Part 3, Chapter 10 Summary: “The Poison Pill: Health Insurance in America”
Chapter 10 discusses the shortcomings of the Affordable Care Act (ACA) and advocates for a single-payer healthcare system in the United States. Ansell argues that the ACA, while expanding insurance coverage, perpetuates existing inequalities and fails to provide universal and equitable healthcare.
The chapter begins by acknowledging that almost 90% of Americans have some form of health insurance under the ACA. However, Ansell asserts that this statistic is misleading, as it overlooks the significant gaps and disparities that remain. He contends that treating healthcare as a right rather than a commodity would address these issues more effectively. As Ansell explains, the ACA has achieved some successes, such as expanding Medicaid in 32 states and reducing the number of uninsured Americans by 20 million. However, about 30 million people remain uninsured, and many others are underinsured. Therefore, Ansell concludes, the ACA does not meet the criteria of universality and equity essential for true health justice.
Ansell also criticizes the ACA for disrupting long-term doctor-patient relationships due to insurance restrictions. He provides the example of Windora Bradley, a long-time patient who struggled with rising insurance costs and changing plans, ultimately losing access to her trusted healthcare providers.
The chapter concludes with a call for a single-payer healthcare system. Ansell argues that the most equitable solution would have been to expand Medicare to cover all Americans. Medicare, introduced in 1965, is a well-liked, cost-effective single-payer system for those over 65. Expanding it to include all citizens would ensure universal access to healthcare, reduce administrative costs, and improve life expectancy. Ansell notes that other industrialized nations with universal healthcare systems, such as Canada, achieve better health outcomes and more equitable care.
Ansell acknowledges the political challenges of implementing a single-payer system, given the powerful opposition from the insurance and pharmaceutical industries. However, he believes that such a system is essential for achieving health justice and improving public health in the United States.
Part 3 Analysis
Ansell focuses more closely on Healthcare as a Human Right VS Commodity in Part 3. He approaches his argument analytically, using data and individual examples to discuss how healthcare being treated as a commodity, implicit racial bias, and resource constraints in disadvantaged communities contribute to poorer health outcomes for minorities and the economically disadvantaged.
Ansell’s analysis of structural violence highlights the impact of under-resourced facilities in predominantly Black neighborhoods. The story of a middle-aged African American woman whose breast cancer was missed due to inadequate diagnostic resources exemplifies the life-and-death consequences of this inequity:
That missed breast cancer held the key to understanding an aspect of premature mortality: access to screening is important for finding breast cancer early—but the quality of that screening is even more critical. We found a screening facility serving Chicago’s black community that found two breast cancers for every thousand women screened, when the correct number should have been at least six. More than half were missed. Add to this injury the insult a black woman feels later when she goes to see a doctor with a bad cancer and is told that her genetics are at fault. (116)
Ansell thus emphasizes that the inadequacies in care do not stem only from a lack of financial and technological investments in healthcare institutions serving disadvantaged communities. Rather, even when these facilities are available and up to date, technicians and doctors tend to act based on unconscious biases, with disastrous results for the health of their patients. Ansell presents implicit bias—the unconscious negative predisposition towards the members of a racial or ethnic group—among healthcare providers as a critical factor in health disparities.
The unconscious biases that lead to different levels of care based on race and insurance status illustrate the insidious nature of racism in healthcare, which cannot simply be resolved through material changes and financial investments. Rather, the change required would be a cultural and ethical one. This bias can result in less-thorough diagnostic evaluations and treatments for Black patients, contributing to their higher mortality rates. Ansell’s use of studies to substantiate these claims adds a layer of empirical rigor to his argument, underscoring the need for systemic changes to address these biases. Finally, Ansell’s recounting of health navigators’ efforts to bridge these gaps offers a glimpse of potential solutions but also underscores the pervasive nature of these disparities, as evidenced by the deplorable conditions at facilities like the one in Washington Park (122).
Overall, Ansell’s line of argumentation in Chapters 9 and 10 acknowledges that some positive changes have taken place over the last decade to address the disparities in healthcare. However, he maintains a critical attitude towards the implementation of the new insurance system. Instead, he proposes expanding Medicare to cover all Americans, which would ensure universal access to healthcare, reduce administrative costs, and improve health outcomes. Ansell’s comparison of the US with other industrialized nations, such as Canada, emphasizes that countries achieve better health outcomes with universal healthcare systems. This comparison highlights the efficacy of single-payer systems and underscores the moral imperative of achieving health justice in the United States.
Nevertheless, Ansell does not discuss that in all states other than Florida, Georgia, Kansas, Mississippi, South Dakota, and Wyoming, Medicaid has been expanded to cover all adults whose income adds up to 138% ($20,783) of the Federal Poverty Level. There is a growing body of literature studying the economic effects and the health benefits of Medicaid expansion, comparing the results in the states that did not opt for Medicaid expansion with the ones that have. A further evaluation of the social effects in impoverished communities would be needed in light of this information, in order to assess whether the current expansion of Medicaid addresses Ansell’s concerns.
