Survey Shows Starkly Different Life Experiences for Lower- and Middle-Income Adults Compared to the Top One Percent

Nearly half of middle-income adults, a majority of lower-income adults’ families have trouble paying for medical bills and prescriptions; three in 10 lower-income adults’ families struggle to pay for food.

    • January 9, 2020
A woman shops in a grocery store.

Princeton, N.J.—With income inequality in the United States at its highest level in 50 years, a new report shows the disproportionate burden that middle- and lower-income household members shoulder when it comes to paying medical bills, buying food, affording housing and absorbing unexpected expenses. 

According to the NPR/Harvard T.H. Chan School of Public Health/Robert Wood Johnson Foundation poll, nearly half (48%) of middle-income adults and a majority (57%) of lower-income adults’ families experience serious problems paying medical and dental bills and affording prescription drugs compared to less than one in 10 of the highest adult earners.

The findings, based on a survey of 1,885 adults living in the United States, reveal how starkly different life experiences are for those earning at least $500,000 a year (the top 1%) and those earning in the middle- ($35,000-$99,999) and lower-income ranges (less than $35,000) when it comes to financial stress, health care, and life satisfaction.  The sample also included people in a higher income category (earning $100,000-$499,999), but the analysis focused mostly on differences between the top one percent and those in the lower- and middle-income categories.

The survey was conducted between July and August 2019, and explores Americans’ personal experiences, values, and views on income inequality, opportunity, and health based on income level.  Although few of the top earners face major financial problems (4%), more than two-thirds of lower income adults (67%) and 34 percent of middle-income adults say they would struggle to pay an unexpected expense of $1,000.

“It is simply unacceptable in a country as wealthy as ours that so many people lack sufficient income to pay for health care, housing or even food,” said RWJF President and CEO Rich Besser. “We need to address income inequality if we truly want everyone to have a fair and just opportunity to live the healthiest life possible.”  

Key highlights of the report:

  • Income matters to health care.  More than seven in 10 Americans across all income categories believe having a higher income allows people to get better health care.  Although a majority of adults across income groups do not believe it’s a top priority for government to reduce income inequality, they say it should be a top priority for the government to ensure universal health care coverage.

  • Medical bills are a big burden.  Fifty seven percent of lower-income adults and 48 percent of middle-income adults report their families have had serious problems paying medical bills, compared to 8 percent of adults in the top income tier. Sizable shares of lower- and middle-income adults have experienced serious problems covering prescription costs, having to forego filling a prescription or cutting back on dosage.

  • Housing is unaffordable for many.  More than one-third (35%) of lower-income adults and about one in five (22%) middle-income adults say their families face serious problems finding an affordable place to live compared to 4 percent of the highest earners.  In addition, 24 percent of lower-income adults and 17 percent of middle-income adults’ families struggle with rent or housing payments, compared to few top earners (1%).

  • Food insecurity is a serious problem.  Thirty percent of lower-income adults and 12 percent of middle-income adults say their families face “serious problems” paying for food compared to less than 1 percent of the highest earners. 

  • Health concerns vary by income. The biggest reported health challenges facing the local communities of all income groups: drug addiction and access to health care. One in five adults across all income groups see drug addiction as the biggest health problem in their local communities. Obesity is also one of the biggest health problems cited by the wealthiest people.  

“These findings reinforce national concerns about the impact of large-scale income inequality in the U.S. today,” said Robert J. Blendon, co-director of the survey and the Richard L. Menschel Professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health. “This report lays out in vivid detail the impact the income gap has on people’s day-to-day lives.”

Despite these challenges, a majority of adults across the income spectrum say the American Dream is still alive and within reach.  The vast majority of parents and grandparents across all income groups also believe future generations will achieve it. 

In fact, a majority across all income groups do not believe the gap between the poorest and richest Americans is a very serious problem. 

Hard work stands out as a “very important” factor for achieving economic success across all income groups.  And while research shows how much social factors like family income, neighborhood and race are tied to economic mobility, fewer than four in ten adults across all income groups believe these play an essential or very important role in economic success in America today. 

  • One-third (33%) of lower-income adults say a person’s racial/ethnic background is an essential or very important factor for achieving economic success, compared to 24 percent for middle-income adults and 27 percent of adults in the top tier.

  • When broken down by race, about half of black adults believe racial/ethnic background is essential or very important to economic success.

When it comes to life satisfaction, income matters.  Ninety percent of adults in the top tier are completely or very satisfied with their lives, compared to 66 percent of middle-income adults and 44 percent of lower income adults.



Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America’s oldest professional training program in public health.



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About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit Follow the Foundation on Twitter at or on Facebook at

Media Contacts

Jordan Reese

Robert Wood Johnson Foundation (609) 627-2233