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Healthy, Wealthy, and Fair$

James A. Morone and Lawrence R. Jacobs

Print publication date: 2005

Print ISBN-13: 9780195170665

Published to Oxford Scholarship Online: October 2011

DOI: 10.1093/acprof:oso/9780195170665.001.0001

Introduction: Health and Wealth in the Good Society

Chapter:
(p.2) (p.3) Introduction: Health and Wealth in the Good Society
Source:
Healthy, Wealthy, and Fair
Author(s):

James A. Morone

Lawrence R. Jacobs

Publisher:
Oxford University Press

Introduction: Health and Wealth in the Good Society

Cholera moves in on a slum lord. Harper’s Weekly, September 12, 1896.

(p.4) Most Americans believe they live in a generous nation, brimming with opportunity. Even poor people cling to the American dream—work hard and you’ll get ahead. If trouble hits, the neighbors are usually quick to lend a hand. When terrorists plowed into the World Trade Center, New Yorkers immediately crowded the hospitals to donate blood. Emergency workers from around the nation rushed to New York to pitch in. The community spirit runs deep in the American grain. In 1835, Alexis de Tocqueville marveled at how “an enlightened self love continually leads [Americans] to help one another.” If your barn burned down, the townspeople helped you raise a new one. From this angle, Americans are a vibrant, energetic people with a long, deep sense of community. We are there to catch our neighbors if they fall on hard times.1

But there is also a darker picture of America. Many people around the world see a county of tight fists and hard hearts. Americans, they believe, valorize wealth, scorn failure, and look out mainly for number one. The richest nation in history tolerates extraordinary poverty. We cut taxes, cheer as the rich get richer, and look the other way as the social safety net decays. Critics see an America enthralled by hard-knuckle capitalism, a land of multimillionaires and hungry children.

Which is the real United States? Both are. We are powerful, rich, and generous. One penny out of every American dollar goes to charity—no other nation comes close. But we also tolerate extremes of wealth and poverty that are hard to fathom. By the mid-1990s, the wealthiest 1% of our households controlled almost half the nation’s financial assets. Most of the world’s billionaires live in the United States. The heads of our largest corporations make more than 300 times as much as the typical American worker and roughly 500 times more than the lowest paid (the numbers vary, depending on how you count—but our ratio stands out in every tally of industrial nations). Contrast this with Japan, where the top executives make about 20 times more than the lowest-paid workers. For that matter, compare American wages today to those of a generation ago: In 1965, the typical (or median) American chief executive officer made 26 times more than a typical worker; by 1989, the ratio had risen to 72:1 and by 2000 it stood at 310:1.2

Meanwhile, at the other end of the spectrum, poor Americans lead hard lives without much help from their more affluent countrymen. Compared to poor people in other industrialized countries, America’s poor work harder and get less assistance—a lower minimum wage, fewer unions, and far less government support. Some seven million Americans are in immediate danger of becoming homeless. Most of them have jobs. And children. Forty-three million people have no health insurance at all; some thirty (p.5) million have too little to cover a serious illness. Almost one in five children lives below the poverty line—almost two in five for black kids. Poor children grow up with the odds stacked heavily against them. Teachers will tell you why Jane can’t read—she’s hungry. Or perhaps she does not see well. An army of people without health insurance adds up to millions of parents who can’t afford the frills—like eye examinations or visits to the dentist.

A look at Americans’ health reveals the astonishing consequences. American girls are born with a life expectancy that ranks nineteenth in the world. (In another survey they fall to twenty-eighth.) Male babies weigh in at thirty-first—in a dead tie with Brunei Darussalam. The average American boy lives 3.5 years less than the average Japanese baby— though the Japanese child is a lot more likely to grow up smoking cigarettes. The American adolescent death rate is twice as high as England’s. These dismal American averages mask vast differences across our population. A male born in some sections of Washington, DC, has a life expectancy 40 years lower than a woman born in rural Minnesota.3 But add us together—look at the whole nation—and our health statistics land us far below the rest of the industrial world. In short, great differences in wealth equate to great differences in health. Surely Tocqueville’s community-minded America would not tolerate such dismal prospects for so many people. Surely a good community would do something.

The American dream imagines a real chance for every person. President Abraham Lincoln put it famously before the Civil War: Any person who is “honest,” “sober,” “industrious,” and “prudent,” he said, would soon get ahead and become a success. But that famous vision of opportunity fades in and out over American history. In today’s political economy, it is slipping completely out of sight for many people. With this volume, we aim to rouse the American spirit of generosity so emblematic of that first America. We focus on the most fundamental inequity: differences in health across our population. This volume charts the inequalities in health, explains why they exist, and suggests what we might do to regain balance. The same underlying message runs through every chapter. A rich and generous nation should not sanction such disparities in life and death, health and disability.

American Troubles

Why do Americans fare so badly in the cross-national health statistics? Why don’t our men live as long as those in, say, Croatia? Our health troubles are the result of three interrelated causes: inequality, poverty, and the way we organize our health care system.

(p.6) Inequality

A now famous study of the British civil service found that with each rung up the bureaucratic ladder, people suffered fewer fatal heart attacks—the clerks and messengers at the bottom were four times more likely to die than the executives at the top. As Ichiro Kawachi explains in chapter 1, health scholars following up this study uncovered a surprising finding that seemed to hold true for one nation after another: the higher the levels of inequality—the more rungs on the economic scale, the greater the distance between richest and poorest—the worse the nation’s health. Longevity seems to be greater in more egalitarian settings.4

Why is this? Perhaps greater equality builds support and trust. Proponents of this view think equality makes for tighter communities and stronger institutions ranging from churches to government. In egalitarian communities, people feel more effective, more empowered. In contrast, inequality generates trouble right down the social ladder. It strains the culture of shared community and creates social stresses. By now, a host of international studies suggest that falling behind creates physiological and psychosocial damage. From this perspective, America’s high mortality rates are the price we pay for the great gap between rich and poor. Fierce economic competition produces winners, losers, and plenty of social troubles.

How should we respond? Some public health advocates draw the simple conclusion: Attack inequality. “Reducing socio-economic and racial-ethnic disparities,” argues sociologist James House, is “the major opportunity for improving health,” both in the United States and around the world.5 But that’s no small job. After all, inequalities do not spring up by accident. Rather, societies build them up through countless political and economic decisions. For example, what kind of safety net protects the poor? Where do we peg the minimum wage? Do we tilt our business policies to encourage or discourage labor unions? Who do we tax, and how much do we tax them? (This may be the single most important question, for it defines how much we will redistribute income.) How do we organize and regulate business competition? How do we oversee our national markets? What do we do about immigration? How do we distribute corporate tax breaks, farm subsidies, low-income housing, kindergartens, and tonsillectomies? The answers to thousands and thousands of basic political and economic questions add up to our distribution of wealth and poverty. And, of course, the final tally is a constantly contested work in progress. (p.7)

A great historical pendulum sometimes swings the United States toward greater equality; at other times toward great disparities. In the past 150 years, there have been two major bursts of inequality: from 1870 to 1910 and from 1979 to today. These eras have been tagged American gilded ages.6

In chapter 2, Lawrence Jacobs explains just how the United States developed its new Gilded Age. Three factors enabled powerful interests to overwhelm egalitarian politics. Well-organized interests wield disproportionate power; the poor participate less; and American labor plays a comparatively weaker hand. To understand the contemporary American political economy, argues Jacobs, start with these three cold political dynamics.

In the past, bursts of inequality eventually triggered egalitarian backlashes. “If I read the temper of our people correctly,” said President Franklin D. Roosevelt at his first inaugural, “we now realize as we have never realized before our interdependence on each other; that we cannot merely take but we must give as well.” Below the quest for wealth, Roosevelt reminded his countrymen, lie the “old and precious moral values” of sharing, of ministering to fellow citizens.7

Of course, egalitarian surges do not simply spring out of moralistic rhetoric. Great concentrations of wealth eventually inspire popular rebellions and provoke populist leaders. President Roosevelt unveiled Social Security looking nervously over his shoulder, as Governor Huey Long stormed out of Louisiana with a jarring scheme to soak the rich— he proposed an income tax rate of 100% on anything over $1 million; a generation later, President Lyndon Johnson signed the Civil Rights Act as black demonstrators thronged the streets. Again and again, rebellions against concentrated wealth and privilege have pushed our leaders to challenge inequality and injustice. Read this way, American history swings between the power of big money (dominating both economics and politics) and a formidable egalitarian tradition that insists on reducing inequities.

Public health advocates who trace our poor health data to inequality are, in effect, calling for a resurgence of the great American egalitarian tradition. As they see it, our health statistics won’t improve, relative to other nations, until we make a new commitment to equality. However, the contemporary global economy pushes us in just the opposite direction—the disparities are growing rapidly and neither political party seems ready to resist the trend. Is there a more accessible path to better national health? (p.8)

Poverty

Many scholars argue that those alarming health statistics flow not from general inequality but, much more directly, from the army of poor and near-poor Americans.8 After all, more than one in ten Americans (almost 33 million) is poor. The Census Bureau labels 40% of them (13.4 million) “severely poor”—they don’t even make it halfway to the poverty line. The numbers are worse for minorities; more than a fifth of blacks and Hispanics are poor. And poverty is shadowed by all kinds of trouble, like hunger (33 million Americans live with food insecurity) and homeless-ness (perhaps as many as 3.5 million a year; about 40% are children).9

In addition, poor neighborhoods face high crime and inadequate education. There are few (safe) parks, well-paying jobs, reliable transportation links, or health care clinics. Instead, poverty attracts danger—too much alcohol and tobacco, illegal drugs and fast foods. One observer after another has gone off to study poor communities and come back with the same report: poor lives are full of stress and the struggle to get by. Jobs are scarce and pay is low. Despite the odds, almost 40% of poor Americans hold jobs—and one in ten (11.5%) manages to work full time all year round. People die younger in Harlem than in Bangladesh. Why? It is not what most people may think—homicide, drug abuse, and AIDS are far down the list. Rather, as the New England Journal of Medicine summed up the evidence, the leading causes of death in poor black neighborhoods are “unrelenting stress,” “cardiovascular disease,” “cancer,” and “untreated medical conditions.”10

From this perspective, the answer to our health dilemma lies in fighting poverty. Conservatives and liberals disagree on the ideal distribution of income and on the best approach to fighting poverty. But most wealthy nations find ways to shelter their citizens from the extreme vicissitudes of global competition. Their success appears to be reflected in their people’s health.

Health Care

It has become fashionable to disparage health care’s contribution to health. The medical system, wrote Aaron Wildavsky in 1977, “affects about 10% of the usual indices for measuring health…most of the bad things that happen to people are at present beyond the reach of medicine.”11 Even some public health advocates have adopted this medical nihilism. A sophisticated attack on health disparities, they argue, would require a (p.9) larger fight against poverty. As people’s lives improve, our health indices will take care of themselves.

But even if poverty is a primary cause of acute illness and early death, this lesson overlooks the basics. Simple health care—annual check-ups, screenings, vaccinations, eyeglasses, dentistry—saves lives and improves well-being. People in poor neighborhoods are familiar with the rush of wonderful, long-delayed health care services that come when someone lands a good job. It’s a uniquely American experience.

No other industrial nation has such yawning gaps in health insurance—43 million without any, 30 million with not enough. The numbers reflect a lot of trouble: uninsured people are slow to seek treatment. Even middle-class parents worry about the next medical emergency or, in many cases, the routine trip to the doctor’s office. Life without health insurance means constantly measuring aches and fevers against the next payday. Changing jobs brings a new set of anxieties about losing medical coverage.

Of course, no health care system treats everyone the same way. But our disparities in care are unusually wide and deep. Emergency-room psychiatrists confront attempted suicides with different protocols. Well-insured people get assigned hospital beds; the uninsured get patched up and sent back to the streets. From diagnostic procedures (prostate screenings, mammograms, and pap smears) to treatment for asthma, the uninsured get less care; they get it later in their illness episodes; and they are roughly three times as likely to have an adverse health outcome. The Institute of Medicine blames gaps in insurance coverage for 17,000 preventable deaths a year.12

The number of uninsured Americans keeps growing. The problem threatens to overwhelm our hospitals and doctors. It loads another stress onto working families. The costs of the system put pressure on employers who inch out of the health insurance business by pushing costs onto their employees. The workers, in turn, risk financial ruin if a member of their family ends up in the hospital. Health bills are America’s largest cause of personal bankruptcy.

These three problems—inequality, poverty, and inadequate health insurance coverage—are all related. Timid reformers often imagine that small changes might add up to serious reform. However, health care is America’s trillion-dollar industry. Coverage for more than 40 million people will be wickedly expensive, requiring a massive redistribution of income from the haves to those who have less. Moreover, from a medical perspective, decent health insurance coverage ought to come with (p.10) renewed efforts to address the worst consequences of poverty—hunger, homelessness, poor education, and bad health habits.

These kinds of reforms will not sneak quietly through the system. They will not come through incremental steps—though small changes can help. Rather, real reform will require powerful grassroots movements and committed leaders. However, before even imagining a path to change, reformers have to face up to the obstacles.

The Barriers to Reform

The sheer size of the inequality problem raises a classic puzzle. Why does the American majority accept political and economic rules that deliver enormous wealth to a small minority? Why do we skew wealth—and health—so much more dramatically than other industrial nations? After all, early American theorists had worried about just the opposite—the majority would use the tax system to soak the rich. “Every shilling with which they overburden the inferior number [of wealthy people],” wrote James Madison, “is a shilling saved to their own pockets.”13 What happened?

Market Power and Horatio Alger Dreams

Many Americans believe that, even if the consequences are painful, a race for riches makes the entire nation more prosperous. After all, look at our own record—great inequality matched by great economic growth. But there is little real evidence for this connection. Cross-national data suggest no link between prosperity and inequality. In fact, just the opposite seems true. The less prosperous nations—Russia and Mexico, rather than France and Italy—are generally the ones that permit vast gulfs between haves and have-nots.14 The data—both across other nations and down through our own history—suggest that the United States might do even better if we once again buffered the markets’ worst consequences.15

Part II addresses the market question directly. In chapter 3, Deborah Stone juxtaposes two sets of values—equality versus markets. Market thinking, she argues, has spread too far into our social realm. It undermines important ideals—like racial justice and decent health care. We can achieve those goals only by reining in and properly overseeing our markets. In chapter 4, Mark Schlesinger shows how American health care has long featured alternate values grounded in medical science and social welfare. However, contemporary political elites have overwhelmed those norms (p.11) by applying a powerful and corrosive kind of market thinking to health policy. He tells us that the market metaphor undermines our own traditional values. Both chapters end with the same forceful claim: Reformers worried about health will have to impose limits on market competition.

Of course, the call to market goes beyond ideology and often reflects blunt self-interest. Market winners are frequently reluctant to share their wealth. They fight fierce battles with less privileged groups—most notably, organized labor and racial minorities. However, today we are witnessing an odd twist in the old class conflicts: market thinking filters into the calculations of the very interests who normally lead the charge for social justice.

In part III, we explain why. Marie Gottschalk argues in chapter 5 that American social policy is not a purely public enterprise but a complicated public-private arrangement. Benefits are not tied to citizenship and overseen by the state; rather, they are often linked to jobs, administered by employers, and supported by public policies. Private employers offer pensions, health insurance, and disability benefits, all backed up by government regulations and tax policies. In most nations, organized labor emerged as a great political champion of universal social policies like national health insurance. In the United States, however, the public-private welfare state reshaped organized labor’s interests. It is not that American labor is politically weak, argues Gottschalk; rather, it has been co-opted by the once generous employee benefit system it helped create. American labor is invested in the market-driven, public-private welfare state.

Market thinking also subtly subverts the power of disadvantaged groups like racial minorities. In chapter 6, Constance Nathanson shows how American interest groups censor themselves. They are constrained by the powerful idea of the market as a grand metric of social worth. Moreover, many diseases have social stigmas. Minority groups, eager to win respectability, do not fight for reform. They overlook their own sick members and fail to push alternative goals and programs.

Taken together, parts II and III describe the powerful, increasingly unbridled force of self-seeking. Market economics overrun our egalitarian norms. Restoring American social justice—addressing American health disparities, mending our community—means taking on and limiting the consequences of those formidable markets.

Chaotic Government

Of course, market ideology and powerful economic interests do not always win. Cries of “socialism” did not stop Medicare, for example. The program passed and became enormously popular. In fact, Medicare and (p.12) Social Security became known as “third rails” of American politics—just touching them could be politically hazardous. Americans may celebrate economic markets. They may be primed to attack government. But that is only one part of the story.16

A more subtle interpretation of American politics focuses on the government itself. “No other nation organizes its government as incoherently as the United States,” concludes one English study of American anti-poverty programs. The political chaos—sometimes celebrated as checks and balances—”leaves most reforms sprawling helplessly in a scrum of competing interests.” Political programs must pass through the executive branch, two independent houses of Congress, the federal bureaucracy, and the many layers of American federalism. Courts intervene at every stage. To pass this kind of gauntlet, proposed programs are first oversold and then heavily compromised.17

The chaotic organization of American politics—full of institutional back alleys in which to mug reforms—is often misread as simple hostility to government action. Consider national health insurance. While Americans have long been skeptical about the idea, both Harry Truman (in 1948) and Bill Clinton (1992) won the presidency touting universal health insurance as a major domestic initiative. What played well on the campaign trail got defeated in Congress. In a parliamentary system, free of checks and balances, one party (or coalition) would control the executive, the legislature, and the bureaucracy. In such a setting, the Truman or Clinton administration would have had the opportunity—in fact, would have been expected—to legislate the reform it promised during the election. If the United States operated under British (or Canadian or German) political rules, it likely would have won national health insurance several times over.18

Over time, the American government has grown increasingly maladroit at winning big policy changes. Instead, it has become geared to deliver narrow benefits to well-organized interests. This is a system that brilliantly services clients. Our government dispenses a steady stream of tax breaks, subsidies, narrowly framed programs, regulatory relief, and special favors. The intricate system spans public and private sectors. Sophisticated analyses of inequality have to be rooted in this American institutional reality. So do calls for action.

Part IV delves into the institutional details. Any major American reform must pass through Congress. In chapter 7, Mark Peterson shows just how and why Congress has become the reformers’ graveyard. But this is a fluid story; Congress is always changing—Truman’s failure in 1946 was very different from Bill Clinton’s in 1993. Each generation of (p.13) reformers faces new challenges and, if they read the institution correctly, fresh possibilities.

A generation ago, reforms stalled in legislatures sometimes won in the courts. In chapter 8, Peter Jacobson and Elizabeth Selvin explain how the era of liberal judicial intervention came to an end—replaced by a cautious judiciary that defers to market winners (with a growing minority eager for a more ambitious conservative activism). Both chapters end on the same note: political institutions will not lead the way to social reform until a powerful popular movement shakes up the current political calculations. Each institutional analysis yields the same advice: Think big.

The Territory Ahead

How to start building the good society? Two classic political strategies point in different directions. Conventional wisdom counsels incremental reform. Take one small step at a time and eventually the little advances will add up. The bold alternative pushes short-term political considerations aside. Only great aspirations will galvanize populist politics and leverage our reluctant state. Throughout American political history, great reforms began with a small group of believers, tirelessly pushing against all the odds.

Which path to follow? As Yogi Berra famously advised, “When you come to a fork in the road, take it.” Parts V and VI examine both strategies: Build on past successes and propose bold departures.

The incrementalists begin with a classic bit of political science wisdom: Every policy changes the ensuing politics. Launching a new program—large or small—shifts the constellation of interests working in the area. Beneficiaries and providers organize to protect and extend their gains. Build onto existing programs, argue proponents, and reform American society one small achievable step at time.

In chapter 9, Colleen Grogan and Eric Patashnik illustrate prospects—and the pitfalls—by tracing Medicaid’s great political arc. The program began inauspiciously. Medicare’s enemies, casting about for a smaller (and frankly less popular) program with which to deflect reformers, proposed Medicaid— “welfare medicine” for the needy. However, once it passed, Medicaid began drifting toward the mainstream. Public officials looking to increase health care coverage repeatedly expanded the program through the late 1980s and 1990s. Today, Medicaid seems poised between mainstream medicine and the welfare program. Some health advocates think Medicaid offers a promising path to reform by (p.14) slowly adding beneficiaries and expanding health services—a politically simple way to get care to more children, uninsured workers, immigrants, and others.

Even very small, local programs—those flying far below the media radar—can add up to meaningful change. In chapter 10, Elizabeth Kilbreth and James Morone investigate a program (operating with state, local, and private funds) that opened health care clinics in poor schools. Because it raised issues like parental control, reproductive health, and substance abuse, the school-based health centers generated enormous opposition around the country. However, against all odds, the programs grew and prospered. Their success stands as a parable for a new generation of activists. The clinics found unlikely champions in state-level public health bureaucrats. The public officials, in turn, organized local parent groups. The new grassroots coalitions cut across race, class, and (sometimes) political ideology. Thanks to these unlikely innovations, a little political jolt—spanning education, health care, and other youth issues—is stirring at the grass roots.

Still, it will take much bolder breakthroughs to squarely address the problems we posed at the start of this volume. As Lawrence Brown suggests in chapter 11, incrementalism is a long, slow, often very helpful, and ultimately inadequate response to American inequality. The task we set ourselves at the start—improving America’s health—will require more than tinkering on the political margin. Small reforms will not remake a political economy that reverberates with self-interest. Each author in this collection independently returns to the same policy advice: seek bold changes. In chapter 12, Benjamin Page suggests how we might begin to do so. He breaks away from conventional thinking and imagines what our government might do—based on what it has done well in the past.

This kind of thinking runs counter to all conventional wisdom. The political mood is unambiguous—this is no time to dream of great societies or bold new deals. However, we confront a galloping inequality that leaves entire groups and neighborhoods far behind. Wealthy people segregate themselves and prosper. As we show in the concluding essay, a global economy powerfully exacerbates the gap between rich and poor. Reversing such formidable trends requires radical rethinking. It cannot happen without a bold assault on those three main interrelated problems—inequality, poverty, and health care coverage.

A long, populist tradition stretches back to America’s founding. Tocqueville celebrated vibrant American communities where people understood that their own best interest—their “self-interest rightly understood”—required the whole community to pitch in and help one (p.15) another, to work together, to see their fates as deeply interconnected. There was nothing in Europe, averred Tocqueville, like the vibrant American sense of community. Our current dilemmas call for a return to that robust, egalitarian spirit of help-your-neighbor.

And that return will require leaders who seize on big reforms and champion them against a contemporary antitax, promarket tide. Along with committed leaders, real change will require another surge of American populism. The final chapters suggest how we might begin to foster that venerable American energy.

We do not enter our calls for change naively. The following chapters detail the many barriers that confront reformers. However, this book is more than a text about equality and health. It is also a manifesto to think big about making a good society. The authors invite you to join us in pushing for an America that is healthy, wealthy, and fair.

Notes

Notes:

(1.) Alexis de Tocqueville, Democracy in America (1835; Garden City, NY: Doubleday, 1969), 526; Jennifer Hochschild, Facing Up to the American Dream: Race, Class and the Soul of the Nation (Princeton, NJ: Princeton University Press, 1995), chapter 3, on poor people clinging firmly to the American dream. For a discussion of the basic mindsets, see James A. Morone, Hellfire Nation: The Politics of Sin in American History (New Haven, CT: Yale University Press, 2003).

(2.) Philanthropic contributions reported in “The New Wealth of Nations,” The Economist (Suppl. 16 June 2001): 15. The data on concentration of wealth gets cut many different ways. See Larry Mishel, Jared Bernstein, and Heather Boushey, The State of Working America: 2002–2003 (Ithaca, NY: Cornell University Press, 2002); they report that the wealthiest 1% of households controls 47.3% of “net financial assets” and 16.6% of household income, 278; median CEO income, 7. Relative income computed by comparing median annual pay for the CEOs of America’s largest 100 corporations and the median annual earnings of full-time workers reported in Ichiro Kawachi, Bruce Kennedy, and Richard Wilkinson, The Society and Population Health Reader: Income Inequality and Health (New York: New Press, 1999), xi; total wealth, xii. See also Stephen Bezruchka, “My Turn: Is Our Society Making You Sick?” Newsweek (26 February 2001): 14; cross-national data on poor (hours worked) from Christopher Jencks, “Does Inequality Matter?” Daedalus 131.1 (Winter 2002): 53.

(3.) Data computed from the United Nations Secretariat, Population Statistics Division, Indicators on Health, 1999; Lynnley Browning, “U.S. Income Gap Widening,” New York Times (25 September 2003): C2.

(4.) Michael Marmot, M. J. Shipley and G. Rose, “Inequalities in Death—Specific Explanation of a General Pattern?” Lancet (5 May 1984): 1003–1006; James Auerbach and Barbara Kivimae Krimgold, eds., Income, Socioeconomic Status and Health (Washington, DC: National Policy Association, 2001), 87 (p.16) .

(5.) James House, “Relating Social Inequalities in Health and Income,” Journal of Health Politics, Policy and Law 26.3 (June 2001): 524.

(6.) See Kevin Phillips, Wealth and Democracy: A Political History of the American Rich (New York: Broadway Books, 2002).

(7.) Franklin Delano Roosevelt, “Inaugural Address,” March 4,1933, The Public Papers and Addresses of Franklin D. Roosevelt II (New York: Random House, 1938), 11–16.

(8.) House, “Relating Social Inequalities,” 527. For an example of the income, race, and health tangle, see David Williams, “Race and Health: Trends and Policy Implications,” Income, Socioeconomic Status and Health, ed. James Auerbach and Barbara Kivimae Krimgold (Washington, DC: National Policy Association, 2001), 67–85.

(9.) Bernadette Proctor and Joseph Dalaker, U.S. Census Bureau, Current Population Reports, Poverty in the United States, 2001 (Washington, DC: U.S. Government Printing Office, 2002).

(10.) Arline Geronimus, John Bound, Timothy A. Waidmann, Marianne M. Hillemeier, and Patricia B. Burns, “Excess Mortality among Blacks and Whites in the United States,” New England Journal of Medicine 335 (1996): 1552–1558; see also Geronimus, “To Mitigate, Resist or Undo: Addressing Structural Influences on the Health of Urban Populations,” American Journal of Public Health 90.68(June 2000): 867–872; and C. McCord and H. P. Freeman, “Excess Mortality in Harlem,” New England Journal of Medicine 322 (1990): 173–177.

(11.) Aaron Wildavsky, “Doing Better and Feeling Worse: The Political Pathology of Health Policy,” Daedalus 106.1 (Winter 1977): 105.

(12.) Institute of Medicine, National Academy of Sciences (Washington, DC: National Academy Press, January 14, 2004).

(13.) James Madison, Federalist Number 10.

(14.) For an overview of the relationship between national wealth and inequality, see Jencks, “Does Inequality Matter?” 49–65.

(15.) On the American historical experience, see, for example, Robert Kuttner, Everything for Sale: The Virtues and Limits of Markets (New York: Knopf, 1997).

(16.) On the political difference between winning and maintaining social policies, see Lawrence Brown, New Politics, New Policies (Washington, DC: Brookings Institution, 1982).

(17.) Peter Marris and Martin Rein, Dilemmas of Social Reform: Poverty and Community Action in the United States (Chicago: Aldine, 1973), 7.

(18.) This argument is from James A. Morone, The Democratic Wish: Popular Participation and the Limits of American Government. (New Haven, CT: Yale University Press, 1998), chapter 8.