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The Rising Prevalence of Severe Poverty in America

A Growing Threat to Public Health
  • Steven H. Woolf
    Correspondence
    Address correspondence and reprint requests to: Steven H. Woolf, MD, MPH, Department of Family Medicine, Virginia Commonwealth University, 1200 East Broad Street, P.O. Box 980251, MCV Station, Richmond VA 23298-0251.
    Affiliations
    Department of Family Medicine, Virginia Commonwealth University, Richmond, Virginia, USA

    Department of Epidemiology and Community Health, Virginia Commonwealth University, Richmond, Virginia, USA
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  • Robert E. Johnson
    Affiliations
    Department of Family Medicine, Virginia Commonwealth University, Richmond, Virginia, USA

    Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
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  • H. Jack Geiger
    Affiliations
    Department of Community Health and Social Medicine, City University of New York Medical School, New York, New York
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      Background

      The U.S. poverty rate has increased since 2000, but the depth of poverty experienced by Americans has been inadequately studied. Of particular concern is whether severe poverty is increasing, a trend that would carry important public health implications.

      Methods

      Income-to-poverty (I/P) ratios and income deficits/surpluses were examined for the 1990–2004 period. The severely poor, moderately poor, and near-poor were classified as those with I/P ratios of less than 0.5, 0.5 to 1.0, or 1.0 to 2.0, respectively. Income deficits/surpluses were classified relative to the poverty threshold as Tier I (deficit $8000 or more), Tier II (deficit or surplus less than $8000), or Tier III (surplus more than $8000). Odds ratios for severe poverty and Tier I were also calculated.

      Results

      Severe poverty increased between 2000 and 2004—those with I/P ratios of less than 0.5 grew by 20%, and Tier I grew by 45% to 55%—while the prevalence of higher levels of income diminished. The population in severe poverty was over-represented by children (odds ratio [OR]=1.69, confidence interval [CI]=1.63–1.75), African Americans (OR=2.84, CI=2.74–2.95), and Hispanics (OR=1.64, CI=1.58–1.71).

      Conclusions

      From 2000 to 2004, the prevalence of severe poverty increased sharply while the proportion of Americans in higher income tiers diminished. These trends have broad societal implications. Likely health consequences include a higher prevalence of chronic illnesses, more frequent and severe disease complications, and increased demands and costs for healthcare services. Adverse effects on children warrant special concern. The growth in the number of Americans living in poverty calls for the re-examination of policies enacted in recent years to foster economic progress.

      Introduction

      Poverty is of great concern to the public health community because of its influence on health status and access to care.
      • Marmot M.G.
      • Wilkinson R.G.
      The poor account for a growing proportion of Americans. Although the nation’s poverty rate declined in the 1990s, since 2000 the United States Census Bureau (USCB) has reported a steady rise in the poverty rate, from 11.3% in 2000 to 12.7% in 2004.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      Children experienced the sharpest increase; the proportion living in poverty rose by 13.4%, from a rate of 15.7% (11.1 million) in 2000 to 17.8% (13.0 million) in 2004.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      Dalaker J. Poverty in the United States: 2000. Current Population Reports, Series P60-214. Washington DC: U.S. Census Bureau, 2001. Accessed at: www.census.gov/prod/2001pubs/p60-214.pdf.

      Other economic trends paint a more positive picture, suggesting that economic growth is bringing greater affluence to the population. In recent years, the Bush administration has reported falling unemployment rates and increases in after-tax income, retail, manufacturing, and overall productivity.

      U.S. White House. Economic growth continues: unemployment rate falls to 4.7 percent. Washington DC, July 7, 2006. Accessed at: www.whitehouse.gov/infocus/economy/.

      This good economic news is tempered by signs of growing income inequality. The Gini index,
      • Kawachi I.
      • Subramanian S.V.
      • Almeida-Filho N.
      A glossary for health inequalities.
      a key measure of inequality, has increased by 3.6% from its most recent low of 0.450 in 1995 to 0.466 in 2004.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      Over the same time period, increases have also been noted consistently in other measures of income inequality, such as the ratio between the highest and lowest quintiles of household income, the Theil and Atkinson indexes, and the mean logarithmic deviation of income.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      • Kawachi I.
      • Subramanian S.V.
      • Almeida-Filho N.
      A glossary for health inequalities.
      Although the evidence is clear that more Americans are poor, how deeply they have sunk into poverty is less certain. We found no current reports on the topic. Our null hypothesis, supported by reports of low unemployment and higher incomes, was that most of the poor are concentrated just below the poverty threshold and that a diminishing proportion of Americans suffer from severe, abject poverty. The alternative—that the poor are slipping more deeply into poverty—would have ominous implications for individuals and families and for the vibrancy of the American community and economy.
      • Rank M.R.
      • Iceland J.
      To clarify which is the case, this analysis grouped the poor into tiers to quantify the depth of poverty in America and to examine temporal trends over time.

      Methods

      The analysis examined the 1990–2004 period to put trends after 2000 into historical context. The study used two measures of the depth of poverty that adjust for inflation and have been tracked consistently by the U.S. Census Bureau (USCB): (1) the income-to-poverty ratio (I/P ratio), and (2) the income deficit/surplus. Both measures are anchored to the poverty threshold,

      U.S. Census Bureau. How the Census Bureau measures poverty (official measure). Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/hhes/www/poverty/povdef.html.

      which the USCB updates annually to account for changes in the Consumer Price Index.
      The income-to-poverty ratio (I/P ratio) is calculated by dividing individual income by the corresponding poverty threshold. The proportion of Americans with an I/P ratio of <2.0 is reported annually for seven subgroups: ratios of <0.5, 0.50 to <0.75, 0.75 to <1.0, 1.0 to <1.25, 1.25 to <1.50, 1.50 to <1.75, and 1.75 to 2.0.

      U.S. Census Bureau. Historical poverty tables. Table 5. Percent of people by ratio of income to poverty level: 1970 to 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/hhes/www/poverty/histpov/hstpov5.html.

      People were classified as severely poor, moderately poor, or near-poor if their I/P ratios were <0.5, 0.5 to 1.0, or 1.0 to 2.0, respectively. The analysis also examined the proportion of Americans with an I/P ratio of >2.0, which was reported by subgroup beginning in 2002.
      The income deficit/surplus is the absolute difference in dollars between household income and the poverty threshold. The study examined USCB reports for 1990 through 2004,

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      U.S. Census Bureau. Poverty in the United States, 1990. Current Population Reports, Series P-60, No. 175. Washington DC: U.S. Census Bureau, 1991. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-175.pdf.

      U.S. Census Bureau. Poverty in the United States, 1991. Current Population Reports, Series P-60, No. 181. Washington DC: U.S. Census Bureau, 1992. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-181.pdf.

      U.S. Census Bureau. Poverty in the United States, 1992. Current Population Reports, Series P-60, No. 185. Washington DC: U.S. Census Bureau, 1993. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-185.pdf.

      U.S. Census Bureau. Income, poverty, and valuation of noncash benefits: 1993. Current Population Reports, Series P-60, No. 188. Washington DC: U.S. Census Bureau, 1995. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-188.pdf.

      U.S. Census Bureau. Income, poverty, and valuation of noncash benefits: 1994. Current Population Reports, Series P-60, No. 189. Washington DC: U.S. Census Bureau, 1996. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-189.pdf.

      Baugher E, Lamison-White L. Poverty in the United States: 1995. Current Population Reports, Series P60-194. Washington DC: U.S. Census Bureau, 1996. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-194.pdf.

      Lamison-White L. Poverty in the United States: 1996. Current Population Reports, Series P60-198. Washington DC: U.S. Census Bureau, 1997. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-198.pdf.

      Dalaker J, Naifeh M. Poverty in the United States: 1997. Current Population Reports, Series P60-201. Washington DC: U.S. Census Bureau, 1998. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-201.pdf.

      Dalaker J. Poverty in the United States: 1998. Current Population Reports, Series P60-207. Washington DC: U.S. Census Bureau, 1999. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-207.pdf.

      Dalaker J, Proctor BD. Poverty in the United States: 1999. Current Population Reports, Series P60-210. Washington DC: U.S. Census Bureau, 2000. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-210.pdf.

      Dalaker J. Poverty in the United States: 2000. Current Population Reports, Series P60-214. Washington DC: U.S. Census Bureau, 2001. Accessed at: www.census.gov/prod/2001pubs/p60-214.pdf.

      Proctor BD, Dalaker J. Poverty in the United States: 2001. Current Population Reports, Series P60-219. Washington DC: U.S. Census Bureau, 2002. Accessed at: www.census.gov/prod/2002pubs/p60-219.pdf.

      Proctor BD, Dalaker J. Poverty in the United States: 2002. Current Population Reports, Series P60-222. Washington DC: U.S. Census Bureau, 2003. Accessed at: www.census.gov/prod/2003pubs/p60-222.pdf.

      U.S. Census Bureau. Income deficit or surplus of families and unrelated individuals by poverty status. Washington DC: U.S. Census Bureau, 2004. Accessed at: http://pubdb3.census.gov/macro/032004/pov/new28_000.htm.

      which present income deficit/surplus data for 20 categories: those with an income deficit of ≥$8000 below the poverty threshold, nine strata for income deficits <$8000, nine strata for income surpluses of <$8000, and those with an income surplus of ≥$8000 above the poverty threshold (see online data table at www.ajpm-online.net). These data were aggregated into four poverty tiers: Tier I (deficit of ≥$8000), Tier IIa (deficit <$8000), Tier IIb (surplus <$8000), and Tier III (surplus of ≥$8000). Because the USCB reports income deficit/surplus data separately for families and for “unrelated individuals” (people who are not members of families), this study uses the same framework for reporting the results. Income deficit/surplus data for unrelated individuals were included only for 1996 and beyond, because the USCB provides incomplete source data for 1990 through 1995.
      The study examined the demographic characteristics of the poverty tiers for 2004, the most recent year for which data are available. Odds ratios and 95% confidence intervals were calculated to determine which characteristics were associated with significantly greater risk of experiencing severe poverty. To explore temporal trends, odds ratios for 2004 were compared with those for 2002 and 2003.
      Relying on the official poverty threshold to measure the prevalence of poverty can be criticized. Many households have difficulty meeting basic expenses at incomes well above the poverty threshold.
      • Shipler D.K.
      The poverty threshold derives from the Orshanksy formula,
      • Fisher G.M.
      The development and history of the poverty thresholds.
      devised in the 1960s based on the assumption that families spend one third of their income on food, a condition that no longer applies. Other criticisms of the poverty threshold are detailed below. This study used the poverty threshold for its calculations because it is the official government measure of poverty and the only metric that has been tracked consistently over the comparison period.

      Results

       Income-to-Poverty Ratios

      Poverty increased in the United States after 2000, but the most dramatic increases occurred among the severely poor. Between 2000 and 2004, the proportion of Americans with I/P ratios <0.5 (an income below 50% of the poverty threshold) increased from 4.5% to 5.4%, a relative increase of 20% (Figure 1, Panel A). The proportion of Americans in moderate poverty (I/P ratio of 0.5 to 1.0) increased less dramatically, from 6.8% to 7.3%, a relative increase of 7.3%. The increase in the near-poor (I/P ratios of 1.0 to 2.0) was modest (an absolute and relative increase of 0.5% and 2.8%, respectively) and erratic (Figure 1, Panel B).
      Figure thumbnail gr1
      Figure 1Proportion of Americans below or near the poverty threshold, 1990–2004. Data are derived from U.S. Census Bureau

      U.S. Census Bureau. Historical poverty tables. Table 5. Percent of people by ratio of income to poverty level: 1970 to 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/hhes/www/poverty/histpov/hstpov5.html.

      and analyzed as described in the text. The poverty threshold is defined by the U.S. Census Bureau based on family size (from one person to nine or more people) cross-classified by presence and number of family members aged <18 years (from no children present to eight or more children present). Unrelated individuals and two-person families are further differentiated by age of reference person (<65 years and ≥65 years). Poverty thresholds for each year are available at www.census.gov/hhes/www/poverty/threshld.html.
      After 2000, the proportion of Americans with the largest incomes (I/P ratios >2.0) decreased by 1.9% (Figure 1, Panel C). In 2002 to 2004, the decline was concentrated among those with I/P ratios of 2.0 to 6.0; the proportion of families with I/P ratios >6.0 remained stable.
      The size of the middle and upper classes and the rise in poverty rates following 2000 represent a reversal in trends observed during the more favorable economic period of 1993 to 2000. During that time, the proportion of Americans below the poverty threshold declined by 25%, from 15.1% to 11.3%,

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      and the proportion with the largest incomes (I/P ratios >2.0) experienced steady growth (Figure 1, Panel C). After 2000, the absolute number of Americans with I/P ratios below 0.5 grew by 30% (3.6 million), from 12.1 million people in 2000 to 15.6 million in 2004; the number with I/P ratios of 0.5 to 1.0 grew by 12% (2.3 million), from 19.0 million in 2000 to 21.3 million in 2004.

      U.S. Census Bureau. People and families in poverty by selected characteristics: 1999 and 2000. Washington DC: U.S. Census Bureau, 2000. Accessed at: www.census.gov/hhes/www/poverty/poverty00/tablea.pdf.

      U.S. Census Bureau. Age and sex of all people, family members and unrelated individuals iterated by income-to-poverty ratio and race. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new01_000.htm.

       Income Deficits and Surpluses

      Between 2000 and 2004, the mean income deficit for the poor grew by 14% among families (from $6820 to $7775) and by 20% among unrelated individuals (from $4388 to $5259), also reflecting an increase in severe poverty. The only category of Americans to increase in size was that with the greatest income deficit (Tier I, ≥$8000 below the poverty threshold) (Figure 2, Panel A). The proportion of families in Tier I increased by 45%, from 3.1% in 2000 to 4.5% in 2004, and the proportion of unrelated individuals in Tier I increased by 55%, from 4.4% to 6.8%. In absolute numbers, Tier I grew by 1.2 million families (52%) and 1.3 million unrelated individuals (63%) between 2000 and 2004. From 1990 to 2004, the proportion of U.S. families in Tier I almost doubled (from 2.3% to 4.5% of families).
      Figure thumbnail gr2
      Figure 2Proportion of families and unrelated individuals in income deficit/surplus Tiers I, II, and III, 1990 to 2004. Data are aggregated from the table posted online (abstracted from U.S. Census Bureau data

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      U.S. Census Bureau. Poverty in the United States, 1990. Current Population Reports, Series P-60, No. 175. Washington DC: U.S. Census Bureau, 1991. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-175.pdf.

      U.S. Census Bureau. Poverty in the United States, 1991. Current Population Reports, Series P-60, No. 181. Washington DC: U.S. Census Bureau, 1992. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-181.pdf.

      U.S. Census Bureau. Poverty in the United States, 1992. Current Population Reports, Series P-60, No. 185. Washington DC: U.S. Census Bureau, 1993. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-185.pdf.

      U.S. Census Bureau. Income, poverty, and valuation of noncash benefits: 1993. Current Population Reports, Series P-60, No. 188. Washington DC: U.S. Census Bureau, 1995. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-188.pdf.

      U.S. Census Bureau. Income, poverty, and valuation of noncash benefits: 1994. Current Population Reports, Series P-60, No. 189. Washington DC: U.S. Census Bureau, 1996. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-189.pdf.

      Baugher E, Lamison-White L. Poverty in the United States: 1995. Current Population Reports, Series P60-194. Washington DC: U.S. Census Bureau, 1996. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-194.pdf.

      Lamison-White L. Poverty in the United States: 1996. Current Population Reports, Series P60-198. Washington DC: U.S. Census Bureau, 1997. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-198.pdf.

      Dalaker J, Naifeh M. Poverty in the United States: 1997. Current Population Reports, Series P60-201. Washington DC: U.S. Census Bureau, 1998. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-201.pdf.

      Dalaker J. Poverty in the United States: 1998. Current Population Reports, Series P60-207. Washington DC: U.S. Census Bureau, 1999. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-207.pdf.

      Dalaker J, Proctor BD. Poverty in the United States: 1999. Current Population Reports, Series P60-210. Washington DC: U.S. Census Bureau, 2000. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-210.pdf.

      Dalaker J. Poverty in the United States: 2000. Current Population Reports, Series P60-214. Washington DC: U.S. Census Bureau, 2001. Accessed at: www.census.gov/prod/2001pubs/p60-214.pdf.

      Proctor BD, Dalaker J. Poverty in the United States: 2001. Current Population Reports, Series P60-219. Washington DC: U.S. Census Bureau, 2002. Accessed at: www.census.gov/prod/2002pubs/p60-219.pdf.

      Proctor BD, Dalaker J. Poverty in the United States: 2002. Current Population Reports, Series P60-222. Washington DC: U.S. Census Bureau, 2003. Accessed at: www.census.gov/prod/2003pubs/p60-222.pdf.

      U.S. Census Bureau. Income deficit or surplus of families and unrelated individuals by poverty status. Washington DC: U.S. Census Bureau, 2004. Accessed at: http://pubdb3.census.gov/macro/032004/pov/new28_000.htm.

      ) and analyzed as described in the text. Unrelated individuals are persons who are not members of families. The U.S. Census Bureau does not provide complete data for unrelated individuals from before 1996. Tier I, income deficit ≥$8000; Tier IIa, income deficit <$8000; Tier IIb, income surplus <$8000; Tier III, income surplus ≥$8000.
      The proportion of the population in Tiers II and III decreased after 2000, a trend that began for Tier II early in the 1990s (Figure 2, Panel B). From 1990 to 2004, the proportion of families in Tiers IIa and IIb fell by one third (from 8.4% to 5.7% and from 12.2% to 8.1%, respectively). The rate of decline in Tiers IIa and IIb was similar after 1996; these tiers were therefore treated as a single group (Tier II) in further analyses.
      After 2000, the proportion of families in Tier III (income surplus of ≥$8000) began to diminish slightly, from 82.6% to 81.7% (Figure 2, Panel C). The proportion of unrelated individuals in Tier III declined from 59.5% in 2000 to 57.5% in 2003 and appeared to recover in 2004 (to 58.4%). Although Tier III decreased in size after 2000, the mean income surplus for Tier-III families increased by 9%, from $56,427 to $61,481 (and by 1% for unrelated individuals).

       Demographic Patterns

      The population experiencing severe poverty was over-represented by children, African Americans, and Hispanics (Table 1, Table 2). As of 2004, the odds of having an income below 50% of the poverty threshold were 69% higher for children aged <18 years than for adults (aged ≥18), and were doubled for children aged <5 years (Table 1). Families with children were 4 times more likely to have Tier-I incomes than were other families (Table 2). Older adults (aged ≥65) were less likely than younger persons to experience severe poverty. Compared with other races, African Americans in 2004 were almost three times as likely to have an I/P ratio of <0.5 (Table 1); African-American householders were more than three times as likely to have Tier-I incomes (Table 2). The odds of having an I/P ratio below 0.5 were 64% greater for Hispanics than for others (Table 1), and Hispanic householders were more than twice as likely to have incomes in Tier I (Table 2). Whites and Asians were less likely to experience severe poverty. Data from the 2002–2004 period suggest that odds ratios for children and minorities diminished during this period.
      Table 1Demographic characteristics of U.S. population, by I/P ratio, 2004 (n=thousands)
      I/P ratioOdds ratio (95% CI) for severe poverty
      Odds ratio for having an I/P ratio <0.5; referent population=I/P ratio >0.5.
      Severely poor <0.5 (n=15,637) (%)Moderately poor 0.5–1.00 (n=21,360) (%)Near poor 1.00–2.00 (n=53,816) (%)2.0–6.0 (n=144,885) (%)>6.0 (n=54,907) (%)
      Age (years)
       <512108641.94 (1.85–2.04)
       <1836352924171.69 (1.63–1.75)
       18–6458535264740.83 (0.80–0.86)
       ≥65612181290.44 (0.42–0.48)
      Female56565450481.23 (1.19–1.27)
      Race/ethnicity
       White
      Individuals who reported this race/ethnicity and no other additional category. African Americans classify themselves as “black” in U.S. Census Bureau surveys.
      65717782870.43 (0.42–0.45)
       African American
      Individuals who reported this race/ethnicity and no other additional category. African Americans classify themselves as “black” in U.S. Census Bureau surveys.
      2722161152.84 (2.74–2.95)
       Asian
      Individuals who reported this race/ethnicity and no other additional category. African Americans classify themselves as “black” in U.S. Census Bureau surveys.
      334460.81 (0.74–0.88)
       Hispanic (of any race/ethnicity)2127231251.64 (1.58–1.71)
      Householder36404038400.88 (0.85–0.91)
      Unrelated individuals
      Individuals who are not in primary families (the householder’s family) or unrelated subfamilies.
      30242215102.30 (2.22–2.39)
      Source: U.S. Census Bureau.

      U.S. Census Bureau. Income, poverty, and valuation of noncash benefits: 1994. Current Population Reports, Series P-60, No. 189. Washington DC: U.S. Census Bureau, 1996. Accessed at: www.census.gov/hhes/www/poverty/prevcps/p60-189.pdf.

      CI, confidence interval; I/P, income to poverty.
      a Odds ratio for having an I/P ratio <0.5; referent population=I/P ratio >0.5.
      b Individuals who reported this race/ethnicity and no other additional category. African Americans classify themselves as “black” in U.S. Census Bureau surveys.
      c Individuals who are not in primary families (the householder’s family) or unrelated subfamilies.
      Table 2Demographic characteristics of U.S. families,
      The U.S. Census Bureau does not publish demographic data for unrelated individuals by income deficit/surplus categories.
      by income tier, 2004 (n = thousands)
      Tier I Income ≥$8000 below poverty, threshold (n=3444) (%)Tier II Income $0–$7999 below/above poverty threshold (n=10,657) (%)Tier III Income ≥$8000 above poverty threshold (n=62,917) (%)Odds ratio for Tier I (95% CI)
      Odds ratio for having Tier I income; referent population: Tiers II and III combined.
      Families with children8160484.31 (3.95–4.70)
      Race/ethnicity of householder
       White
      Individuals who reported this race and no other additional category. African Americans classify themselves as “black” in US Census Bureau surveys.
      6474840.36 (0.34–0.39)
       African American
      Individuals who reported this race and no other additional category. African Americans classify themselves as “black” in US Census Bureau surveys.
      301993.54 (3.28–3.82)
       Asian
      Individuals who reported this race and no other additional category. African Americans classify themselves as “black” in US Census Bureau surveys.
      3340.69 (0.56–0.84)
       Hispanic (of any race/ethnicity)2424102.35 (2.17–2.55)
      Families with female householder and no spouse5738136.76 (6.30–7.25)
      a The U.S. Census Bureau does not publish demographic data for unrelated individuals by income deficit/surplus categories.
      b Odds ratio for having Tier I income; referent population: Tiers II and III combined.
      c Individuals who reported this race and no other additional category. African Americans classify themselves as “black” in US Census Bureau surveys.
      Fragmented family units face a heightened risk of severe poverty. Compared to other families, the odds of having a Tier-I income in 2004 were almost seven times higher among families led by a female householder with no spouse (Table 2). Unrelated individuals—people not in families—were twice as likely to have an I/P ratio <0.5 (Table 1).

      Discussion and Conclusions

      A rise in poverty rates is important because of the enormous difficulties faced by the poor in meeting the most basic human needs (e.g., food security, clothing, housing, health) and in obtaining the means to escape their conditions (e.g., education, jobs, higher earnings). This suffering alone is sufficient cause for concern among those who advocate social justice, but rising poverty rates are also relevant to those who reject a moral duty to help the poor. The global competitiveness of the U.S. economy suffers if workers are too poor to obtain an education and modern job skills, the government loses tax revenue and spends more on public assistance because of poverty, and communities fall victim to urban decay, crime, and unrest.
      • Rank M.R.
      • Iceland J.
      This study found that the recent increase in poverty rates is explained largely by a dramatic upsurge in severe poverty, refuting our null hypothesis. The rise in severe poverty after 2000 was substantial. In relative terms, the proportion of Americans with I/P ratios less than 0.5 grew by 20%, and Tier I grew by 45% and 55% among families and unrelated individuals, respectively. In absolute terms, the number of Americans with I/P ratios less than 0.5 grew by 30%, and the number of families and unrelated individuals in Tier I grew by 52% and 63%, respectively.
      In contrast, increases in moderate poverty were less striking. Indeed, Tier II has been shrinking since the early 1990s. The fall in the proportion of families and unrelated individuals with incomes within $8000 of the poverty threshold displayed a similar pattern for those above (Tier IIb) and below (Tier IIa) the poverty threshold (Figure 2, Panel B). The 18 income strata within Tier II (see Methods) exhibited similar trends and rates of decline, which were collectively distinct from the temporal patterns observed for Tiers I and III (Figure 2, Panels A and C). The population with an income deficit of at least $8000 below the poverty threshold therefore appears to be vulnerable to a different experience than those with incomes closer to the poverty threshold. Therefore, analyses that focus only on the population below the poverty line, mixing Tier I with members of Tier II, may lose sight of such trends.
      The growth in Tier I, set against reductions in Tiers II and III, suggests that severe poverty may be producing a “sinkhole” effect on income. Just as a sinkhole causes everything above it to collapse downward, families and individuals in the middle and upper classes appear to be migrating to lower income tiers that bring them closer to the poverty threshold. Relative to 2000, by 2004 Tiers II and III had experienced net losses of 0.5% and 0.9% of American families, respectively, whereas Tier I had experienced a net growth of 1.4% of families. The 2.4% absolute increase between 2000 and 2004 in the proportion of unrelated individuals in Tier I was explained by a 1.3% reduction in Tier II and a 1.1% reduction in Tier III.
      One would expect this sinkhole effect to be accompanied by an overall decrease in median income in the United States, which was indeed the case. The USCB reports that U.S. household income, adjusted for inflation, declined by 3.6% between 2000 and 2004, from a median of $46,058 to $44,389.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      Our findings have not, to our knowledge, been published previously. Using the search terms “severe poverty” and “deep poverty,” we searched Social Sciences Citation Index and PubMed from 2001 forward and found no articles on the topic. A Google search retrieved information about severe poverty globally but only USCB reports and statements by advocacy organizations provided information that relate to the United States.
      The USCB does announce year-to-year increases in the poverty rate at annual press briefings, and news reports have noted the steady rise in rates after 2000—but the media have not emphasized the trend. Between 2002 and 2005, the Washington Post and New York Times ran eight news articles about the census statistics, ranging from 400 to 1410 words in length, but the articles devoted a median of two sentences to the temporal increase in the overall poverty rate.

      Pearlstein S. U.S. poverty rate rises, income drops; increase in ranks of poor is first in 8 years. Washington Post, September 25, 2002, p. A3.

      Kaufman L. City poverty rate shows first rise in 5 years. New York Times, September 26, 2002, p. B3.

      Weisman J. U.S. household incomes fell, poverty rose in 2002; Democrats say Bush policies are to blame; White House points to recent pickup in economic recovery. Washington Post, September 28, 2003, p. A20.

      Clemetson L. More Americans in poverty in 2002, Census study says. New York Times, September 27, 2003, p. A1.

      Connolly C, Witte G. Poverty rate up 3rd year in a row; more also lack health coverage. Washington Post, August 27, 2004, p. A1.

      Polgreen L. New York City’s poverty rate holds steady while nation’s rises. New York Times, September 15, 2004, p. B7.

      Weisman J, Connolly C. Poverty rate continues to climb; 2004 census data show labor market is still struggling. Washington Post, August 31, 2005, p A3.

      Leonhardt D. Poverty in U.S. grew in 2004, while income failed to rise for 5th straight year. New York Times, August 31, 2005, p. A9.

      The USCB press briefings have largely omitted discussion of severe poverty. The only briefing to comment on severe poverty after 2000 occurred on September 26, 2003, when 2002 data were released. By that time, the proportion of individuals with I/P ratios less than 0.5 had grown from 4.5% in 2000 to 4.8% in 2001 and to 4.9% in 2002.

      U.S. Census Bureau. Historical poverty tables. Table 5. Percent of people by ratio of income to poverty level: 1970 to 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/hhes/www/poverty/histpov/hstpov5.html.

      The USCB spokesman said only this: “The 14.1 million people with incomes less than half their thresholds represent 4.9% of the population … percentages not different from 2001.”

      Weinberg DH. Press briefing on 2002 income and poverty estimates. Washington DC: U.S. Census Bureau, September 26, 2003. Accessed at: www.census.gov/hhes/www/income/income02/prs03asc.html.

      Nothing further was said about severe poverty, and the topic was omitted entirely from press briefings in 2004 and 2005 (although the proportion had risen to 5.3% by 2003 and 5.4% in 2004).

      Weinberg DH. Press briefing on 2003 income and poverty estimates from the Current Population Survey. Washington DC: U.S. Census Bureau, August 26, 2004. Accessed at: www.census.gov/hhes/www/income/income03/prs04asc.html.

      Nelson C. News conference on 2004 income, poverty, and health insurance estimates from the Current Population Survey. Washington DC: U.S. Census Bureau, August 30, 2005. Accessed at: www.census.gov/hhes/www/income/income04/prs05asc.html.

      The press briefings were recently investigated by the U.S. Government Accountability Office.

      U.S. Government Accountability Office. Data quality: expanded use of key dissemination practices would further safeguard the integrity of federal statistical data. Washington DC: U.S. Government Accountability Office, 2006 (GAO-06-607). Accessed at: www.gao.gov/new.items/d06607.pdf.

      Reflecting what they hear at press briefings, journalists covering the census reports have also reported little about severe poverty. A New York Times editorial on August 31, 2004 did say: “[T]he positive news on the number of people in poverty masks an alarming trend. The number of people in extreme poverty—that is, subsisting on less than half the income defined as the poverty line—stands at 15.3 million, higher than at any time since the Census Bureau began collecting data 28 years ago.”

      Poverty and health (editorial). New York Times, August 31, 2004, p. A20.

      A year later it had reached 15.6 million.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      Images from New Orleans in late 2005 following Hurricane Katrina brought temporary attention to the plight of the severely poor, but even these reports said little about the growth of the problem throughout the country.
      This study’s findings are consistent with a recent Federal Reserve Board analysis of the net worth of U.S. families, which it conducts every 3 years. Net worth is the difference between family assets and liabilities. For the 2001–2004 period, the Federal Reserve reported that median net worth rose by 1.5%, considerably less than in 1998–2001 (10.3%). Although median net worth increased by 4% for families above the 90th percentile for income (from $887,900 to $924,100), median net worth declined by 11% (from $8400 to $7500) among families below the 20th percentile and by 13% (from $39,600 to $34,300) among families between the 20th and 40th percentiles. The Federal Reserve reported that mean income for all U.S. households, adjusted for inflation, decreased by 2.3%, from $72,400 to $70,700, consistent with the sinkhole effect that we observed.

      Bucks BK, Kennickell AB, Moore KB. Recent changes in U.S. family finances: evidence from the 2001 and 2004 Survey of Consumer Finances. Federal Reserve Bull 2006. Accessed at: www.federalreserve.gov/pubs/bulletin/2006/financesurvey.pdf.

      Similarly, an analysis for the Brookings Institution found that only the top 10% of the income distribution has experienced growth in real wages and salaries equal to or greater than the rate of growth in the economy.

      Dew-Becker I, Gordon RJ. Where did the productivity growth go? Inflation dynamics and the distribution of income. Washington DC: Brookings Institution, 2005. Accessed at: http://brookings.edu/es/commentary/journals/bpea_macro/forum/200509bpea_gordon.pdf.

      Several methodologic considerations pertain to our work. First, the increase in poverty rate observed in this study may be temporary; data beyond 2004 could not be assessed. A recession occurred in 2001, and poverty rates climbed and then stabilized following recessions in 1969, 1973, 1981, and 1990.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      U.S. Census Bureau. Historical poverty tables—periods of recession. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/hhes/www/poverty/histpov/recessn.html.

      Second, the study relied entirely on USCB data to measure income trends; such data are the nation’s only primary benchmark for tracking poverty rates. Third, census data are subject to sources of error documented by the USCB.

      U.S. Census Bureau. Source and accuracy of estimates for income, poverty, and health insurance coverage in the United States: 2004. Washington DC: U.S. Census Bureau. Accessed at: www.census.gov/hhes/www/income/p60_229sa.pdf.

      Fourth, although the poverty threshold is adjusted for inflation, an income deficit of $8000 means less over time.
      Fifth, the highest income categories (I/P ratios above 2.0, and an income surplus of at least $8000) are broad and encompass the middle and upper class. Sufficient data were lacking to stratify incomes within this large group. Although as a whole this group decreased as a proportion after 2000 (Figure 1, Figure 2), a highly affluent subgroup may have increased in size. The USCB reports that the proportion of households with incomes of at least $250,000 increased from 1.2% in 2000

      U.S. Census Bureau. Income distribution to $250,000 or more for households: 2000. Washington DC: U.S. Census Bureau, 2001. Accessed at: http://pubdb3.census.gov/macro/032001/hhinc/new07_000.htm.

      to 1.5% in 2004,

      U.S. Census Bureau. Income distribution to $250,000 or more for households: 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/hhinc/new06_000.htm.

      and the ratio between the income of households at the 90th and 10th percentiles increased from 10.58 to 11.07.

      DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-229.pdf.

      This concentration of wealth might explain the aforementioned increase in indices of income inequality (e.g., Gini coefficient) and the observation that Tier-III families decreased as a proportion but experienced a 9% increase in their average income surplus.
      Fifth, this study did not explore the causes of the observed trends or potential remedies. Lower wages and investment earnings and changes in social programs may account for lower income-adjusted incomes. Like its predecessors, the recession of 2001 would have been expected to fuel poverty by causing higher unemployment, a reduction in work hours, and stagnation of family income.

      Iceland J, Kenworthy L, Scopilliti M. Macroeconomic performance and poverty in the 1980s and 1990s: a state-level analysis. Madison: University of Wisconsin, Institute for Research on Poverty, 2005. Accessed at: www.irp.wisc.edu/publications/dps/pdfs/dp129905.pdf.

      The economic recovery that often follows a recession can mitigate these conditions, although some contend that changes in public policies (e.g., reduced welfare assistance and a weaker social safety net) and unfavorable job opportunities may account for the continued growth in poverty after 3 years of economic recovery.

      Children’s Defense Fund. The unprotected recession: record numbers of families have no work and no welfare in 2001. Washington DC: Children’s Defense Fund, 2003. Accessed at: www.childrensdefense.org/pdf/noworknowelfare.pdf.

      The increase in severe poverty and the overrepresentation of children that were observed in this study may also relate to demographic characteristics among immigrants, who accounted for 42% of U.S. population growth in the 2000–2005 period.

      U.S. Census Bureau. Cumulative estimates of the components of population change for the United States and states: April 1, 2000 to July 1, 2005. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/popest/states/tables/NST-EST2005-04.xls.

      Other possibilities for increased poverty include decreased earnings by parents, diminished real value of income-transfer programs (welfare, or temporary aid to needy families), and increases in female single-parent households.
      • Wood D.
      Effect of child and family poverty on child health in the United States.
      The study did not explore potential solutions to poverty, such as education; we recently demonstrated that almost 200,000 U.S. deaths could be averted each year if all adults had the life expectancy of those who attended college.

      Woolf SH, Johnson RE, Phillips RL Jr, Philipsen M. Giving everyone the health of the educated: would social change save more lives than medical advances? Am J Public Health. In press.

      Finally, these analyses are anchored to the poverty threshold, a metric with known limitations. As noted earlier, the Orshansky formula incorporates outdated assumptions about living expenses. Food now accounts for approximately one sixth of family budgets,

      Willis J. How we measure poverty: a history and brief overview. Silverton: Oregon Center for Public Policy, 2000. Accessed at: www.ocpp.org/poverty/how.htm.

      and the formula ignores modern-day expenses such as child care and higher costs for housing and transportation. The threshold makes no adjustment for geographic variation in the cost of living. In communities such as Washington DC and San Francisco, the average rental for a one-bedroom apartment exceeds the entire poverty threshold for an individual or couple.

      Harrington DB. Top 10 Out-of-Control Rental Markets. Move, Inc. Accessed at www.move.com/Rentals/Apartment%20Search%20Tips/Content00026388.aspx?poe=move.

      The State of the Rental Market. RentalGuide.com. Publishing Group, Inc. Accessed at http://www.rentalguide.com/rentalmarket.html.

      Although these factors suggest that the federal poverty threshold underestimates the prevalence of poverty, the exclusion of some income categories in the Orshanksy formula might serve to inflate the poverty rate. For example, the formula excludes cash and noncash transfers received by the poor, such as public assistance (e.g., government insurance, food stamps, housing aid, tax credits), tax benefits, and gains from stock holdings. Experimental alternative poverty measures that have been suggested to correct for the deficiencies in the Orshansky formula include some that generate higher prevalence estimates for poverty (e.g., measures proposed by the National Academy of Sciences) and some that generate lower estimates (e.g., measures considered by the USCB).
      • Citro C.F.
      • Michael R.T.
      Measuring poverty: a new approach.

      Short K. Experimental poverty measures: 1999. Current Population Reports, Series P60-216. Washington DC: U.S. Census Bureau, 2001. Accessed at: www.census.gov/prod/2001pubs/p60-216.pdf.

      U.S. Census Bureau. Alternative poverty estimates in the United States: 2003. Current Population Reports. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-227.pdf.

      U.S. Census Bureau. The effects of government taxes and transfers on income and poverty: 2004. Washington DC: U.S. Census Bureau, February 2006. Accessed at: www.census.gov/hhes/www/poverty/effect2004/effectofgovtandt2004.pdf.

      Others advocate the use of relative, rather than absolute, measures of poverty.
      • Kawachi I.
      • Subramanian S.V.
      • Almeida-Filho N.
      A glossary for health inequalities.

      Cassidy J. Relatively deprived. How poor is poor? New Yorker, April 2006.

      These considerations speak to the imprecision of the official poverty threshold in quantifying the true poverty rate—for 2003, when the official poverty rate was 12.5%, the estimated poverty rate from experimental measures ranged from 7.4% to 14.5%

      U.S. Census Bureau. Alternative poverty estimates in the United States: 2003. Current Population Reports. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-227.pdf.

      —but this imprecision bears little on the temporal trends reported here because the magnitude of the variation has held constant over time. From 1987 to 2003, alternative measures that yield lower estimates for the poverty rate followed the same slope as did the official measure.

      U.S. Census Bureau. Alternative poverty estimates in the United States: 2003. Current Population Reports. Washington DC: U.S. Census Bureau, 2005. Accessed at: www.census.gov/prod/2005pubs/p60-227.pdf.

      The exclusion of cash and noncash assistance from the official measure could conceivably act as a confounding variable in our key finding—that the growth of severe poverty was greater than for moderate poverty—had the severely poor received more of such assistance. There is little evidence of such a difference, however. For example, in 2004, the severely poor (I/P ratio of less than 0.5) and the moderately poor (I/P ratio of 0.5 to 1.0) differed little in their receipt of cash or noncash transfers (93% vs 95%, respectively)

      U.S. Census Bureau. People in households that received means-tested cash or noncash assistance including school lunch, 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new25_002_02.htm.

      or Medicaid (76% vs 75%, respectively).

      U.S. Census Bureau. People in households in which one or more members were covered by Medicaid, 2004. Washington, DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new25_005_05.htm.

      Differences noted for some forms of aid, such as food stamps (56% vs 47%, respectively),

      U.S. Census Bureau. People in households that received food stamps, 2004. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new25_004_04.htm.

      were unlikely to account for the dramatic differences in the growth of moderate and severe poverty observed in this study.
      The risk of slipping into severe poverty is not shared equally across the population. This study found that African Americans and Hispanics face a greater risk than do whites or Asians. In 2004, African Americans accounted for 9% of those with an I/P ratio of greater than 2.0,

      U.S. Census Bureau. Age and sex of all people, family members and unrelated individuals iterated by income-to-poverty ratio and race. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new01_000.htm.

      but they constituted an increasing proportion of those with progressively lower incomes (16%, 22%, and 27%, respectively, of Americans with an I/P ratio of 1.0 to 2.0, 0.5 to 1.0, and less than 0.5). The burden of supporting a family in severe poverty falls disproportionately on minorities. In 2004, African Americans led the households of 9% of families in Tier III, but 19% of families in Tier II and 30% of families in Tier I. Hispanics led 10% of families in Tier III but 24% of families in Tiers I and II.
      The most troubling finding is that the risk of severe poverty is greater among children than among adults. Children aged less than 5 years face the greatest risk (Table 1). In 2004, one of three Americans with incomes less than 50% of the poverty threshold—a total of 5.6 million people—was a child. The risks are enormous among minority children: Children account for 44% and 45%, respectively, of Hispanic and African Americans with I/P ratios less than 0.5.

      U.S. Census Bureau. Age and sex of all people, family members and unrelated individuals iterated by income-to-poverty ratio and race. Washington DC: U.S. Census Bureau, 2005. Accessed at: http://pubdb3.census.gov/macro/032005/pov/new01_000.htm.

      Families with children account for 48% of families in Tier III and 81% of families in Tier I (Table 2).
      The public health implications of increasing poverty are profound, given how strongly social class is linked with premature mortality, disease, and mental illness.
      • Marmot M.G.
      • Wilkinson R.G.

      National Center for Health Statistics. Health, United States, 2005. Hyattsville MD: National Center for Health Statistics, 2005. Accessed at: www.cdc.gov/nchs/data/hus/hus05.pdf.

      Marmot MG, Davey Smith G, Stansfeld SA, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet 199;:337:1387–93.

      • Kennedy B.P.
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      Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis.
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      Income differences in mortality: a register-based follow-up study of three million men and women.
      • Daniels N.
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      The poor have greater exposure to risk factors, such as those caused by homelessness, substandard housing, and environmental pollutants.
      • Hwang S.W.
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      Interventions to improve the health of the homeless: a systematic review.
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      Environmental justice: human health and environmental inequalities.
      They experience greater rates of smoking, physical inactivity, and obesity,

      National Center for Health Statistics. Health, United States, 2005. Hyattsville MD: National Center for Health Statistics, 2005. Accessed at: www.cdc.gov/nchs/data/hus/hus05.pdf.

      • Miech R.A.
      • Kumanyika S.K.
      • Stettler N.
      • Link B.G.
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      • Chang V.W.
      Trends in the association of poverty with overweight among US adolescents, 1971–2004.
      in part because impoverished neighborhoods are not conducive to healthy lifestyles (e.g., having built environments for walking
      • Humpel N.
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      • Leslie E.
      Environmental factors associated with adults’ participation in physical activity: a review.
      and supermarkets that offer healthy food choices
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      • Diez Roux A.V.
      Associations of neighborhood characteristics with the location and type of food stores.
      ); these communities are also targets for the promotion of cigarettes, alcoholic beverages, and fast foods.
      • Gardiner P.S.
      The African Americanization of menthol cigarette use in the United States.
      • Alaniz M.L.
      • Wilkes C.
      Pro-drinking messages and message environments for young adults: the case of alcohol industry advertising in African American, Latino, and Native American communities.
      • Block J.P.
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      • DeSalvo K.B.
      Fast food, race/ethnicity, and income: a geographic analysis.
      The poor lack jobs that offer health insurance and cannot afford to purchase insurance themselves.
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      • Gil I.
      • et al.
      Health benefits in 2005: premium increases slow down, coverage continues to erode The average cost of family coverage now exceeds the average yearly income of minimum-wage Americans.
      Fully 31% of those below the poverty threshold are uninsured, and 23% report no usual source of care.

      National Center for Health Statistics. Health, United States, 2005. Hyattsville MD: National Center for Health Statistics, 2005. Accessed at: www.cdc.gov/nchs/data/hus/hus05.pdf.

      Cost remains a barrier even among those eligible for Medicaid or indigent services, due to greater cost shifting to patients and out-of-pocket expenditures.
      • Johnson T.J.
      • Rimsza M.
      • Johnson W.G.
      The effects of cost-shifting in the State Children’s Heath Insurance Program.
      • Galbraith A.A.
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      Out-of-pocket financial burden for low-income families with children: socioeconomic disparities and effects of insurance.
      • Himmelstein D.U.
      • Warren E.
      • Thorne D.
      • Woolhandler S.
      Illness and injury as contributors to bankruptcy.
      These barriers often impel the poor to forego care or to seek it episodically for acute problems, missing opportunities for prevention and allowing disease complications to intensify.
      • Ross J.S.
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      • Busch S.H.
      Use of health care services by lower-income and higher-income uninsured adults.
      The quality of care that they do receive is compromised by the fragmented infrastructure in underserved communities, where facilities and clinicians are often lacking in number, resources, and cultural sensitivity.
      • Georges C.A.
      • Bolton L.B.
      • Bennett C.
      Quality of care in African-American communities and the nursing shortage.
      Sullivan Commission
      For these various reasons, the poor on average receive inferior health care, have worse health status, and require greater use of resources.

      National Center for Health Statistics. Health, United States, 2005. Hyattsville MD: National Center for Health Statistics, 2005. Accessed at: www.cdc.gov/nchs/data/hus/hus05.pdf.

      Agency for Healthcare Research and Quality. National healthcare disparities report, 2005. Rockville MD: Agency for Healthcare Research and Quality, 2005. Accessed at: www.ahrq.gov/qual/nhdr05/nhdr05.htm.

      • Asch S.M.
      • Kerr E.A.
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      • et al.
      Who is at greatest risk for receiving poor-quality health care?.
      Emergency department visits and the length of hospital stays among the poor are more than twice those of the general population.

      National Center for Health Statistics. Health, United States, 2005. Hyattsville MD: National Center for Health Statistics, 2005. Accessed at: www.cdc.gov/nchs/data/hus/hus05.pdf.

      These health effects result partly from inadequate income but also reflect other interrelated characteristics of the poor, such as education, race, ethnicity, and environmental factors. Inadequate education, which often accompanies poverty, is a barrier to making wise personal health choices and to advancing to suitable jobs that provide higher earnings and health insurance. Health status and health care differ by race and ethnicity, even after adjustment for socioeconomic status.
      Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine
      • Geiger H.J.
      Race and health care—an American dilemma?.
      Given that the population in poverty is over-represented by immigrants, some might wonder whether the link between poverty and health is refuted by the “healthy immigrant” phenomenon, in which new immigrants enter the country in comparatively better health than their native-born counterparts or than immigrants who have lived in the United States for more than 10 years.
      • Stephen E.H.
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      This phenomenon may result in part from selection factors in the population who choose to emigrate and from conditions that cause deterioration in health as residents in the United States (e.g., acculturation, adoption of unhealthy behaviors, poor access to healthcare services). Exposure to poverty is likely to exacerbate these conditions and to accelerate the process by which the health of immigrants deteriorates.
      The adverse health experienced by those below the poverty threshold is amplified for severe poverty. The relationship between income and life expectancy climbs steeply at the extremes of poverty and plateaus at higher income levels.

      World Bank. World Development Report 1993: investing in health. Oxford: Oxford University Press, 1993. Accessed at: www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/1993/06/01/000009265_3970716142319/Rendered/PDF/multi0page.pdf.

      Health outcomes for the severely poor are worse than for those in moderate poverty.
      • Pappas G.
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      • Seguin L.
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      The rising prevalence of severe poverty, which is reported here, is therefore cause for concern. As the number of people in severe poverty increases, we would expect growth in the prevalence of chronic illness, more frequent and severe complications, and greater demands and costs for healthcare services. The number of uninsured will grow, further burdening public programs (e.g., Medicaid) and facilities for indigent care. Severe poverty also threatens the economy: The severely poor cannot contribute to a vibrant workforce, and their health needs require society to pay higher taxes or insurance premiums to offset treatment costs.
      Perhaps the most lasting consequences are for children, the age group that we found to be at greatest risk for severe poverty. Children are especially vulnerable to harm from severe poverty because of its influences on perinatal outcomes, growth, nutrition, parenting, safety, development, emotional health, access to health care, adolescent pregnancy, cognition, and educational success.
      • Wood D.
      Effect of child and family poverty on child health in the United States.
      • Stevens G.D.
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      Children exposed to severe poverty are at greater risk of experiencing unemployment, learning disabilities, mental illness, physical disease, substance abuse, and crime as adults.
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      • Wadsworthx M.E.
      Changing social factors and their long-term implications for health.
      • Singh-Manoux A.
      • Richards M.
      • Marmot M.
      Socioeconomic position across the lifecourse: how does it relate to cognitive function in mid-life?.
      • Lawlor D.A.
      • Ebrahim S.
      • Davey Smith G.
      Adverse socioeconomic position across the lifecourse increases coronary heart disease risk cumulatively: findings from the British women’s heart and health study.
      • Feinstein L.
      • Bynner J.
      The importance of cognitive development in middle childhood for adulthood socioeconomic status, mental health, and problem behavior.
      • Hertzman C.
      The biological embedding of early experience and its effects on health in adulthood.
      • Werner E.E.
      • Smith R.S.
      They are also more likely to remain in poverty as adults,

      Hertz T. Understanding mobility in America. Washington DC: Center for American Progress, 2006. Accessed at: www.americanprogress.org/atf/cf/{E9245FE4-9A2B-43C7-A521-5D6FF2E06E03}/HERTZ_MOBILITY_ANALYSIS.PDF.

      thereby perpetuating the cycle for their children.
      • Kahn R.S.
      • Wilson K.
      • Wise P.H.
      Intergenerational health disparities: socioeconomic status, women’s health conditions, and child behavior problems.
      • Goldman N.
      Social inequalities in health disentangling the underlying mechanisms.
      According to one report, only 6% of children who grow up in the lowest quintile of income attain the highest income quintile as adults (compared to 42% of those who grow up in the highest income quintile).

      Hertz T. Understanding mobility in America. Washington DC: Center for American Progress, 2006. Accessed at: www.americanprogress.org/atf/cf/{E9245FE4-9A2B-43C7-A521-5D6FF2E06E03}/HERTZ_MOBILITY_ANALYSIS.PDF.

      In recent years, government policy for fostering upward mobility among the lower and middle classes has been to promote vibrant commerce as a vehicle for job creation and to reduce outlays for social services to finance tax cuts and other incentives to “grow the economy.” The findings reported here suggest that this policy has improved incomes for only a small proportion of the population—primarily the most affluent class—while poverty rates at the other end of the spectrum have increased. Millions of Americans, over-represented by children and minorities, have entered conditions of extreme poverty. After 2000, Americans subsisting under these conditions grew as a class more than any other segment of the population. Potential solutions to poverty are formidable and politically difficult,
      • Rank M.R.
      • Iceland J.
      • Sachs J.D.
      • Phillips K.
      but the first step is to recognize the problem, which to date has received little exposure, and its implications for public health and society. Policymakers should consider our data in judging whether policies enacted in recent years have helped or hindered the public.
      No financial conflict of interest was reported by the authors of this paper.

      Appendix

      Table 1Number of families and unrelated individuals, by income deficit/surplus, 1990 - 2004
      Table thumbnail grt1a

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