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Americans who have had the misfortune of becoming seriously sick know that the country’s health care system is deeply broken, even if you have insurance. But a new study out Friday highlights the widening gap in who gets to be healthy. Over a 25-year period leading up to 2017, it found, health inequality has largely either stagnated or gotten worse.

Past research studying the health gap in the U.S. has often looked at the big picture, examining life expectancy (spoilers, rich people live longer than poor people) or specific diseases like cancer. But the current study, published in JAMA Network Open, took a more ground-level approach.

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The researchers turned to annual survey data from the Centers for Disease Control and Prevention, which asked people how they felt about their health in general, as well as how many healthy days—both physically and mentally—they had experienced in the past month. Based on this data, which was collected from 1993 to 2017, the team also created different measures of health equity, tracking the size of disparities across income, sex, and race or ethnicity.

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On the bright side, the researchers found, the relatively small gap between black and white Americans significantly improved over the 25-year span, in terms of both self-reported health and number of healthy days. But health equity in general between different groups of Americans remained the same for self-reported health, and it got worse when it came to the number of healthy days people on average had. Health justice—a measure looking at how a person’s race, income, or sex correlated with their health—also got worse over time. And the health gap between the poor and well-off expanded as well.

“The results of this study show a worrisome lack of progress on health equity during the past 25 years in the United States,” the authors wrote.

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Of course, there’s plenty of other research showing that things aren’t working out well for many Americans, health-care wise. The poorer you are, the more likely you are to have drinking water contaminated with lead and other toxins as well as especially polluted air, while health care costs, including insurance, are skyrocketing for an ever-growing number of people. And the lack of health care coverage alone is thought to directly contribute to tens of thousands of deaths in America every year, though data on the topic is somewhat limited.

That all of this is happening despite the modest gains in coverage and protections provided by the Affordable Care Act, which mostly came into effect in 2014, should be seen as a sign that fundamental changes are needed to ensure health equality in the U.S.—changes that go beyond explicit health care reforms, according to the authors.

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“The analysis here hints that increasing income disparities may be associated with stagnant health equity,” they wrote. “If this is in fact the case, policies that reduce the prevalence and penalties associated with poverty would be a clear starting point to improving health equity.”