1、IntroPreviouslyGrossman modelIndividuals make choices about their health based on time constraints,budget constraints,and utilityOptimal amount of health(H*)changes based on decisions about tradeoffsHow does socioeconomic status(SES)affect health and choices about health?Does health determine SES?Or
2、 does SES determine health?Use empirical evidence to explore these questionsThe pervasiveness of health disparitiesHealth disparities are everywhereHealth Disparity:(def)differences in health-incidence,prevalence,mortality,and burden of disease-between specific populationsex:death rates for all canc
3、er types for both men and women are highest among African Americans1Ubiquitous worldwide across races,educational attainments,employment grades,and incomesBroadly across all socioeconomic statuses(SES)Health disparities are everywhereBy education:College graduates are 25%more likely to survive to ag
4、e 68 than high school dropoutsBy race:Hispanics report better health status than black individualsWhite individuals report better health then both Hispanic and black individualsHealth deteriorates with age across all races,but disparities persistHealth disparities across incomeGenerally:high-income
5、individuals self-report a higher health status than those of lower incomesFor most conditions,the poor exhibit more incidences of diseaseSome exceptions like Bronchitis-no difference Hay fever-the rich appear to be diagnosed with hay fever more oftenMay be explainable if richer children visit the do
6、ctor more often and hence,are more likely to be diagnosed Disparities even with universal insuranceEven in countries with universal health insurance,health disparities persistCanada:Self-reported health status for children at high SES better than children of low SES(Currie and Stabile 2003)England:W
7、e discuss the Whitehall studies laterTheories to explain health disparitiesWhy do health disparities exist?Reasons/theoriesEarly life eventsIncome levelsStress of being poorWork capacityImpatienceAdherence to medical advicePolicy importance of understanding causes of disparities before addressing th
8、emWhat causes what?Does bad health cause low SES?Does low SES cause bad health?Are there other factors?Hypotheses for health disparitiesEfficient producerThrifty phenotypeDirect incomeAllostatic loadIncome inequalityAccess to careProductive timeTime preference(The Fuchs hypothesis)The Grossman model
9、 and health disparitiesRecall MEC indicates the return on each additional unit of health capitalDifferent SES groups may have different MECsWhy?Each hypothesis posits a different reasonThe efficient producer hypothesisHypothesis:better-educated individuals are more efficient producers of health than
10、 less well-educated individualsGrossman predicts that people who are more efficient health producers will have higher H*Lleras-Muney(2005)find that an additional year of schooling caused 1.7 year increase in life expectancy in 1920s USHence,education improves healthThe efficient producer hypothesisP
11、ossible causal mechanismsPossible reasons for positive correlation between health and education?Lessons in school help students to take better care of themselvesSchooling helps students be more patient when it comes to payoffs of investments(like health)Better-educated more likely to adhere to treat
12、ment regimensThe efficient producer hypothesisThrifty phenotype hypothesisGenetic reasons for being inefficient at producing healthDeprivation of resources(food)in utero and early childhood leads to activation of“thrifty”genes that are useful for sparse environmental conditionsThese“thrifty”genes go
13、od for scarce environments but bad in conditions of abundanceMore likely to develop diabetes,obesity,and other disorders later in lifeDisparities arise because poorer individuals are more likely to have resource deprivation early in lifeThe thrifty phenotype hypothesisThrifty phenotype hypothesisUse
14、 natural experiments to test this hypothesisA randomized experiment that randomly deprived some children in utero and not others would be pretty unethical!Natural experiments use environmental shocks that naturally create control and treatment groupsEx:earthquakes,famine,snowstormsGood natural exper
15、iment eliminates selection biasThe thrifty phenotype hypothesisThe Dutch famine studyNatural experiment:Dutch famine in WWII(Rosebloom et al.2001)Holland suffered a famine due to a German blockade of foodCreated two baby groups:Those in utero during famineThose conceived after famineTwo groups are s
16、imilar,except for in utero deprivationSo hopefully no selection bias!Findings:Babies in utero during famine had higher rates of diabetes and obesity in adulthoodThe thrifty phenotype hypothesisThe direct income hypothesisHypothesis:disparities exist because rich people have more resources to devote
17、to healthRich individuals have an expanded PPF because of extra financial resourcesExpanded PPF=higher H*that can be obtainedThe direct income hypothesisAllostatic load hypothesisHypothesis:Prolonged or repeated stress is unhealthy and can cause an increased rate of agingIn the Grossman model,aging
18、is represented by rate of depreciation of health capital High stress load leads to a higher The allostatic load hypothesisThe Whitehall studyWhitehall study by Marmot at al.(1978,1991)Compares health status of British civil servantsBritish civil servants relatively homogenous in background and share
19、 workplace environmentsAll British citizens have the same access to health care through the National Health ServiceFindings:Disease morbidity and mortality rates highest for low-grade civil servantsLow-grade civil servants reported more stressful work and home environmentsThe Allostatic Load Hypothe
20、sisIncome inequality hypothesisHypothesis:Health disparities are caused by an unequal distribution of incomeRelated to the allostatic load hypothesisMore equal societies are less stressful and therefore healthierPolicy implications?If theory is true then policy makers should aim at reducing inequali
21、ty within a communityThe health status of a society may decline even if average income rises if income becomes more concentratedThe Direct Income HypothesisAccess to care hypothesisHypothesis:Those with high incomes can afford more generous health insurance compared to those of low incomeBut health
22、disparities persist in countries with universal health insuranceCanadian youth(Currie and Stabile 2003)British civil servants(Marmot et al.1978,1991)both countries have equal access to health care!The access to care hypothesisProductive time hypothesisSES differences are caused by disparities in hea
23、lthBad health leads to lower productive time and therefore less time to produce incomeOreopoulos et al.(2008)and Black et al.(2007)study siblings growing up in same household Those with worse health during infancy have higher mortality rates,lower educational achievement,and lower adult earningsThe
24、productive time hypothesisThe Fuchs hypothesisBad health does not cause low SES,and low SES does not cause bad healthA third factor time preference-causes both!Health and SES both determined by willingness to delay gratificationPeople who are willing to delay gratification are more willing to invest
25、 in things like education and healthPeople willing to delay gratification have high discount factors The Fuchs hypothesisConclusionEach theory has supporting evidence and each can explain some socioeconomic health disparitiesKey takeaways:Better-educated people generally have better health even with the same resourcesHealth events early in life affect health into adulthoodStress plays an important role in creating health disparitiesEqualizing access to care does not eliminate health disparitiesThere is a two-way relationship between health and SES
